What Is an Explanation of Benefits?

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DEFINITION

An explanation of benefits (EOB) statement provides details about a health insurance claim that has been processed.

Definition and Examples of an Explanation of Benefits

An explanation of benefits statement is sent to you after a health insurance claim. It lays out the details of the service, the charges from the provider, the amount covered by insurance, and how much money is still due. Each time they provide services to you, doctors, dentists, and other medical professionals will submit claims to your insurance. This is how they receive payment. In turn, the insurance company will send you an EOB to inform you of the claims submitted, how much is being covered by insurance, and how much you owe.

Any portion of the medical expense not covered by the insurance company, such as a deductible or a co-pay, will be billed by the provider. These charges should be paid directly to the provider.

Tip

The EOB may look like a bill, but it is not. It can also be hard to make sense of. You may need to call your insurance company to ask any questions about the EOB.

The precise layout and form of the EOB will vary by insurance company, but a simple EOB will include:

  • A summary of your account with important identifying information and claim number.
  • The details of the claim, including the date and specific services provided.
  • The accounting, which includes the price of the service, the amount that your insurance is covering, and the difference between the two. (This is sometimes called the "adjustment," "amount allowed," or "contracted agreement.")
  • An optional summary of copays, deductible, and coinsurance.

Many insurance providers, such as Blue Cross Blue Shield, will have sample EOBs available on their website. You can review them to become familiar with what EOBs look like and how the information is presented.

How an Explanation of Benefits Works

An EOB can help you avoid paying more than you should for healthcare. Look over an EOB when it arrives in the mail; then, compare it to your bills to ensure that you pay the correct amount. If you find an error on a bill from a doctor or other provider, call your insurance company for help addressing the discrepancy.

What if you don't understand why you owe money or simply are having trouble reading the EOB? You can also call your insurance company or your healthcare provider to explain the details.

If you owe money, ask the insurance company whether this payment will be put toward your out-of-pocket deductible. If you need clarification on charges for certain services, you can ask the provider to explain the services and charges for each. If you think you have been charged in error, ask the provider to go over the entire EOB, line by line to help you see whether a mistake occurred.

Just as healthcare providers can make billing errors, coding errors can occur when insurance companies process EOBs. If you do not understand something on your EOB, or you think your insurance policy covers an expense that was not paid, call your insurance company for an explanation.

Important

What if you find an error on your EOB, and the insurance company cannot fix it promptly, or if there is a disagreement? You may need to have the benefit reviewed in a more lengthy process or file a formal dispute.

How to Get an Explanation of Benefits

The explanation of benefits statement often arrives via mail. In most cases, it closely resembles a medical bill.

Most insurance companies now provide you with online access to your account, which can include digital access to EOBs. If you don't already have online access to your account, check with your insurance company about how to get it.

Once you've set up an online account, check to see what digital access options your insurer offers. Most will let you sign up for email alerts when EOBs are available. This can allow you to view them immediately, so you won't have to wait for them to arrive in your mailbox.

Key Takeways

  • An EOB is a statement from your insurer. It outlines which portion of a claim it has paid and what portion you will have to pay.
  • You should get an EOB any time your healthcare provider bills your insurance.
  • Always take a close look at an EOB to be sure the charges are correct.
  • Compare EOBs to the bills you receive from providers, and reconcile them before you make a payment.

Article Sources

  1. Blue Cross Blue Shield of Michigan. "How Do I Read My Blue Cross Blue Shield of Michigan Explanation of Benefits?" Accessed July 2, 2021.

  2. Texas Department of Insurance. "Understanding an Explanation of Benefits." Accessed July 2, 2021.

  3. University of Utah. "Explanation of Benefits." Accessed July 2, 2021.