An Explanation of Benefits (EOB) is a document provided by an insurance company to the policyholder and the healthcare provider, detailing the outcome of a medical claim. It serves as a summary of how the insurance company processed the claim, the amounts billed, the amounts covered, and any remaining balances or patient responsibilities.
Here’s what you can typically find in an EOB:
Patient Information: The EOB includes the patient’s name, policy number, and other identifying information.
Claim Information: The EOB provides details about the claim, such as the claim number, date of service, and the provider’s name and contact information.
Billed Charges: The EOB shows the total amount charged by the healthcare provider for the services rendered.
Allowed Amount: This is the portion of the billed charges that the insurance company considers eligible for coverage based on the policy’s benefits and fee schedules. The EOB specifies the allowed amount for each service.
Deductibles: If the policy has a deductible, the EOB indicates the portion of the allowed amount that applies towards the deductible and the remaining deductible balance.
Copayments and Coinsurance: The EOB outlines any copayments or coinsurance amounts that the patient is responsible for, typically calculated based on the allowed amount.
Coverage Details: The EOB provides a breakdown of how the insurance company covered each service, including the percentage of coverage and any limitations or exclusions that apply.
Denied or Not Covered Services: If the insurance company denies coverage for certain services, the EOB will explain the reasons for the denial and any appeal procedures.
Provider Payments: The EOB displays the amount the insurance company paid to the healthcare provider for each service.
Patient Responsibility: The EOB specifies the amount the patient is responsible for paying, including deductibles, copayments, coinsurance, and any non-covered services.
Remaining Balance: If there is any balance remaining after the insurance company’s payment and the patient’s responsibility, the EOB indicates the amount owed to the healthcare provider.
EOBs are essential for patients to understand the financial aspects of their healthcare services and to verify that the claims were processed correctly by the insurance company. Healthcare providers use EOBs to reconcile their billing records, track payments, and communicate with patients regarding their financial responsibilities.
It’s important for patients to carefully review their EOBs and compare them with their own records and receipts. If there are any discrepancies or questions, they should contact their insurance company or healthcare provider for clarification or resolution.