Reading an explanation of benefits can be confusing. On this page, you’ll learn what an explanation of benefits is for, and how to read one.
See what an explanation of benefits looks like (PDF)
What’s an explanation of benefits?
An explanation of benefits (EOB) shows you the total charges for your visit.
An explanation of benefits isn’t a bill.
It helps you understand how much your health plan covers, and what you'll pay when you get a bill from your provider.
What’s on an explanation of benefits?
General information about you and your health plan
The explanation of benefits includes information about:
- You (the patient)
- Your health plan
- Who provided your care, and when it was provided
- A reference number called the claim number
- The person who gets reimbursed for any overpayments, called the payee
It will also list your health plan’s phone number. Call your health plan if you have questions about finding a provider or what services they cover.
Details about your claim(s)
The explanation of benefits gives you details about your care, like:
- The date of service
- A service description. This explains what service you had, like a medical visit, lab test, or screening.
Information about your bill
The explanation of benefits lists the cost of your care, and how much your health insurance company will pay.
- “Provider Charges” is the amount your provider bills for your visit.
- “Allowed Charges” is the amount your provider will be paid. This may not be the same as the Provider Charges.
- “Paid by Insurer” is the amount your health plan will pay to your provider.
What you owe
What You Owe, or Patient Balance, is the amount you owe after your insurer has paid everything else.
You may have already paid for part of the Patient Balance. The Explanation of Benefits only shows what you owe, not if you’ve already paid for it.
Your bill should not be higher than the Patient Balance. If it is, talk to your provider.
Remark code
A remark code is a note from the health plan that explains more about the costs, charges, and paid amounts for your visit.
The code is usually 2 or 3 letters and numbers. Check the bottom of the explanation of benefits for a description of each code.
FAQs
In the upper right portion of your EOB you'll find general information. If a payment was made to the provider, you'll see the check details in the top boxes. Below that are things like the claim and policy number, your ID numbers, both the insured's and the patient's name, as well as the provider's name and address.
What is the explanation of benefits for dummies? ›
An EOB is a statement from your health insurance plan describing what costs it will cover for medical care or products you've received. The EOB is generated when your provider submits a claim for the services you received. The insurance company sends you EOBs to help make clear: The cost of the care you received.
What does an EOB look like? ›
The explanation of benefits gives you details about your care, like: The date of service. A service description. This explains what service you had, like a medical visit, lab test, or screening.
What are EOB explanation codes? ›
An Explanation of Benefits (EOB) code corresponds to a printed message about the status or action taken on a claim. Providers will find a list of all EOB codes used with the corresponding description on the last page of the Remittance Advice.
What does deductible amount mean on EOB? ›
Your deductible is the amount that you must pay each year for covered services before your plan starts paying benefits.
What does the total charge represent on an EOB? ›
Total Charged: Billed charges before negotiated adjustments, network discounts, copays, deductibles or any denied charges.
What do you do with explanation of benefits? ›
You may receive an EOB from your health plan after your visit with the provider. It will show you the total charges for your visit and how much you and your health plan owe. An EOB is NOT A BILL. You can also use it to track how you and your family use your coverage.
What is the full explanation of benefits? ›
An Explanation of Benefits (EOB) is a statement that your insurance company sends that summarizes the costs of health care services you received. An EOB shows how much your health care provider is charging your insurance company and how much you may be responsible for paying. This is not a bill.
How do you explain employee benefits? ›
Employee benefits are any forms of perks or compensation that are provided to employees in addition to their base salaries and wages. A complete employee benefits package may include a health insurance plan, life insurance, paid time off (PTO), profit sharing, retirement benefits, and more.
What are the 5 pieces of information found on an EOB? ›
The EOB will show a variety of information, including details about the medical treatment, the amount that was billed, the amount that the health plan allows for that service, the amount the health plan paid (if any), and the amount that the patient owes.
You should always save your Explanation of Benefits until you get the final bill from your doctor or health care provider. Insurance companies make it easy for members to view past EOBs online, so there's no need to keep a paper copy if you have an online account.
Who usually receives an explanation of benefits? ›
Usually, the insurer sends the EOB to the primary person on the health plan. If an employer provides the insurance, the employee usually receives the EOB, including EOBs for a spouse and dependents on the plan.
What does a clean claim mean? ›
A "clean claim" means a claim that does all of the following: Identifies the health professional, health facility, home health care provider, or durable medical equipment provider that provided service sufficiently to verify, if necessary, affiliation status and includes any identifying numbers.
Can providers charge more than EOB? ›
Anything billed above and beyond the allowed amount is not an allowed charge. The healthcare provider won't get paid for it, as long as they're in your health plan's network. If your EOB has a column for the amount not allowed, this represents the discount the health insurance company negotiated with your provider.
What is the reason code 45 on EOB? ›
Examples of Claim Adjustment Reason Codes are: 45 = $xx. xx; a common informational code letting providers know that their charges exceed the fee schedule maximum allowable by the amount indicated. You would find this code on paid lines on a claim.
How do you read a medical billing statement? ›
How to read your medical bill
- Name and address. ...
- Statement date. ...
- Name and address of the provider(s) or facility. ...
- Account number. ...
- Date(s) of the service. ...
- Description of services or supplies. ...
- The costs of services or supplies. ...
- How to pay the bill.
The providers' network status: “Yes” means the provider is in network, while “No” shows the provider is out of network. Usually, your cost share is lower for covered services from in-network providers. The day or date the patient received the services. The name and code for the services.
Can I view my medicare EOB online? ›
EOBs are usually mailed once per month. Some plans give you the option of accessing your EOB online. Your EOB is a summary of the services and items you have received and how much you may owe for them.
How is the total allowed amount calculated? ›
Allowed Amount = Total charges less Contractual Adjustments If no contractual adjustment is posted then total charges equals the allowed amount. Denial adjustments are excluded from the calculation as denials do not impact allowed amount.
