Final answer:
The form that contains payment details from a managed care organization for a claim is the Explanation of Benefits (EOB). It includes payment information, billed amounts, and patient responsibilities such as deductibles and copayments. Option B is correct.
Step-by-step explanation:
The form that provides information from the managed care organization that paid on the claim is option B, the Explanation of Benefits (EOB). The EOB is a statement from the insurance company or managed care organization detailing what costs were covered for medical care or services provided.
It contains information regarding payments made by the insurer, the amounts billed by the healthcare provider, and any applicable deductibles or co-payments. The other forms mentioned, such as the UB-04 and CMS 1500, are used for different purposes. The UB-04 and UB-92 are used by hospitals and other providers to bill the insurance company, while the CMS 1500 is used by non-institutional providers and suppliers to bill Medicare Part B and other insurers.