An Explanation of Benefits, commonly referred to as an EOB, is a statement from your health insurance company providing payment details for medical service(s) you recently received. The EOB explains what portion of services were paid by your insurance plan and what part you are responsible for paying. Your insurance company sends it to you when your health care provider submits a claim on your behalf.
How do EOBs work?
An Explanation of Benefits statement is a summary of the service, the charges from the provider, the amount covered by insurance, and how much money is still due. Each time healthcare services are provided the providers will submit claims to your insurance carrier.
The insurance company sends you EOBs to summarize:
- What services were provided
- The cost of the care you received
- Charges based on in-network contracted amounts
- Any out-of-pocket medical expenses you will be responsible for
Is an EOB a Bill?
No, an EOB is not a bill. It is a statement outlining the medical services received and details how you and your current plan will share in the billed charges. This is not to be used as a form of payment for any outstanding medical bills. The EOB should be matched to the bill received from the provider to make sure all discounts according to the negotiated rates have been correctly applied.
How to read and EOB:
EOBs state the costs associated with your care and are standard among insurance companies. Here is a description of what you can typically expect an EOB to contain:
- Your Doctor’s Name – When you receive your EOB, make sure the doctor listed on your EOB is correct, and your claim was not mis-coded. This can happen when doctors in the same system have similar names, like “Matthews” and “Mathews.” If one doctor is a Primary Care Physician (PCP), and the other is a Specialist, you could accidentally get charged for a more expensive service just because the doctor was coded incorrectly. If you see multiple doctors, make sure the doctor listed on the EOB matches the date of your service appointment.
- Date of Service – If you receive an EOB and the date of service listed is not the date you received care, contact customer service at your health insurance company and ask for an additional explanation. They typically have a more detailed description of service on file. Sometimes you receive an EOB after a doctor has read a lab result, which isn’t necessarily on the date you had lab work done, but you wouldn’t know the background unless you called for further detail.
- Charges for the Service – This is the total amount of the service you received. The figure gives you a basis in order to calculate the rest of your discounts and financial responsibilities. The “Allowed Amount” or “Total to Provider” is what you actually have to pay after your preferred provider discount, if your claim is for an in-network service.
- Member Responsibility
- Copay - You may have paid a flat rate for a service, which is indicated in this section. Copays do not apply to deductible but do apply to the maximum out-of-pocket.
- Deductible - This is how much of the bill you are responsible for before reaching your deductible.
- Coinsurance - Coinsurance requires you to pay a certain percentage of your medical bill once the plan deductible has been met. The percentage is typically 20%, 30% or 50%, depending on your health insurance coverage.
What if you don’t receive an EOB?
If you are a member of a network or your doctor’s office has your insurance information, most likely they will submit the insurance claim on your behalf. But if they don’t have that capability you may have to submit the claim yourself. In that case, you may get a bill from your doctor or healthcare provider before you get an EOB.
In any case, don’t pay your bill until you receive an EOB for that service. That way you can be sure your insurance company paid their portion and you’re not paying more than you owe.
Of course, if you ever have questions about a bill or an EOB, you can always call Member Services at your insurance company for answers.
What should you do next after receiving an EOB?
Always save your EOB forms until you get the final bill from your healthcare provider. Compare the amount you owe on the EOB to the amount on the bill. If they match, that’s the amount you will need to pay. Keep in mind that often you will get more than one EOB if you received more than one type of service or treatment, or if you received treatment on more than one day. You may have a stack of several, which you should save. Your bill should itemize the services you received so you can see what was billed and what was covered for each.
If there is an error, what next?
If your EOB contains any kind of mistake, or if you suspect that it does, you should call your health insurance company and your health care provider. Unresolved errors with EOBs is the responsibility of the policy owner. To ensure proper documentation is provided Stateside recommends keeping all EOBs and billing payment information until the matter is resolved.
STATESIDE CAN HELP!
Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs.
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