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Explanation of Benefits (EOB) Dissected

Explanation of Benefits EOB Dissected

Explanation of Benefits EOB Dissected

You know that document that comes from your health insurance company that you almost always think is a bill at first?  Yep, that one - The Explanation of Benefits or EOB.  You're not alone!  Many people confuse it with a bill which is why SOMEWHERE on the EOB it should say boldly THIS IS NOT A BILL.

It's all about claims.  Whenever you use your health plan for services or goods from a healthcare provider, a claim is submitted on your behalf. (If you go out-of-network you may have to file your own claim.  That's a whole different article.)  When a claim is submitted, your health insurance company generates an EOB.  It shows how your benefits cover the cost of the service or goods from your provider and what you are LIKELY to owe.

On the EOB, you will see:

  • Service / Product received
  • Dates of service
  • Amount billed - That's the full amount billed by your provider to your health plan
  • Amount paid by your health plan - That's the portion of the charges your benefits cover
  • Amount paid by another source - Examples of other sources include: other health insurance (you can have primary insurance and secondary insurance), automobile insurance, homeowners' insurance, disability insurance, etc.
  • Copay - a specific dollar amount you are required to pay for doctor visits or prescriptions. Copays are usually paid at the time of service.
  • Coinsurance - A percentage of the bill you are required to pay for doctor visits or prescriptions.
  • Deductible - the out-of-pocket amount you are responsible for before your insurance company starts paying for you.  Depending on your plan, you may have a deductible for all care or just for some types of care.
  • Amount not covered - The portion of the bill that's not covered or eligible for payment under your plan.
  • Your total responsibility - This section details the portion of the bill that is LIKELY your responsibility to pay. This amount might include your copay, coinsurance, and deductible. However, THIS IS NOT A BILL.  You do not need to send payment when you receive your EOB.  Wait for a bill.
  • Claim Notes - When present, these notes provide general information about the claim. For example, if the claim was denied because your provider submitted the same claim twice, a note would tell you that the claim was denied as a duplicate. 

If you ever have questions about an EOB or a bill, call your health insurance company!  It's always good to make sure you completely understand what your services were and what you're being billed for before paying.  Your health insurance company can help.

Special Note: If you received a reimbursement from your health insurance company that was intended for a provider, it is your responsibility to pay the provider.  If you're unsure about any money you've received, call your health insurance company.  

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The information and materials herein are provided for general information purposes only and are not intended to constitute legal or other advice or opinions on any specific matters and are not intended to replace the advice of a qualified attorney, plan provider or other professional advisor. This information has been taken from sources believed to be reliable, but there is no guarantee as to its accuracy. This communication does not constitute a legal opinion and should not be relied upon for any purpose other than its intended educational purpose.

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