After you file a claim with your visitor medical insurance company, and your claim has been processed, you’ll receive an EOB from your insurance. An EOB, or Explanation of Benefits, is a document that includes everything you need to understand your claim. It may include information such as an itemized breakdown of your claim, which claims were paid or not paid, PPO network discounts, and more. It will detail how much of your services or treatment from a provider is covered by your benefits and how much is your responsibility, although your EOB is not a bill.
While an EOB is extremely helpful to understand your processed claim, you may find it difficult to interpret at first glance. Let’s take a deeper dive into how to read an EOB and what information is typically included in your insurance policy’s Explanation of Benefits.
What’s Included in an EOB?
While the information in your Explanation of Benefits will vary depending on your policy’s insurance company and your individual plan, it generally includes key details that will help you better understand the outcome of your claims. The majority of EOBs will include the following information:
Customer Service Information - This includes the insurance company’s customer service contact information and the date that your EOB was prepared.
Provider and Patient Details - Your EOB should include your name and patient ID (as assigned by the provider) along with the provider’s name and group number.
Date of Service - The date of which you received your treatment/service listed in the EOB.
Service Code - This represents the type of service you received from the provider.
Total Charge - This is the full amount billed by the service provider to your insurance policy.
Not Covered - The portion of the total charge that is ineligible or not covered by the insurance plan’s benefits.
Reason Code - The reason code, or remark, corresponds to a reason as to why there is an amount that is not covered. The corresponding remark to the reason code can typically be found later in your EOB.
Discount Amount - This represents the discount you received on your services by visiting a provider that is in network.
Covered by Plan - This is the amount of total changes that is eligible for your insurance plan’s benefits.
Less Deductible - This represents the amount that you are responsible for during each period of coverage.
Less Copay - Copay is the amount that you are responsible for and is typically set for specific services, for example, paying $25 for each doctor’s visit. You will typically pay your copay at the time of your visit or service.
Amount Subject to Coinsurance - This is the total benefit amount that is subject to coinsurance.
Less Patient Share of Coinsurance - This represents your share of the coinsurance.
Payment Amount - How much the insurance plan is paying (per claim line).
Total Patient Responsibility - How much the insurance company has determined is your responsibility to pay after the plan’s benefits have been applied.
Total Payment - The total amount paid for by the insurance plan.
Payment Details - The details of where the payment was sent by the insurance company, including the check/wire number and payment amount.
Accumulator and Amount - The amount that has been applied to your deductible or out-of-pocket amounts.
Claims Denied Due to Missing Information
If you see on your EOB that your claim has been denied due to missing information or documentation, your claim can be reopened. Any documents that are needed by the insurance company will be noted in the Remarks section on your EOB. The Remarks section is located at the bottom of your EOB and contains important information as it pertains to your claims status. Check the documents required, gather this information, and send the documents to the insurance company to reopen and reprocess your claim.
Once you receive your EOB, it is recommended to review it in full and ensure that the details of your visit(s) and total charges are correct. If you notice a discrepancy on your Explanation of Benefits, you can contact the insurance company using the customer service information provided on the EOB.
Read Your EOB With Confidence
Remember, your Explanation of Benefits isn’t a bill. It is a breakdown of your claim(s) to help you better understand how much of your treatment or services are covered by your insurance plan and how much is your responsibility.