How to Get Your Explanation of Benefits (EOB)
Master your healthcare finances. Learn to access, interpret, and manage your Explanation of Benefits for true cost clarity and control.
An Explanation of Benefits (EOB) is a document sent by your health insurance company after you receive medical care. It provides a detailed summary of the services you received, how your insurance plan processed the associated costs, and any amount you might owe. An EOB is not a bill for payment.
Understanding Your Explanation of Benefits
An EOB outlines financial details of your medical services, showing how your health plan applied benefits. It lists the healthcare provider’s name, the service date, and describes the service received. This description often includes a Current Procedural Technology (CPT) code, a standardized code for medical procedures like an office visit, laboratory test, or imaging.
The EOB details the “Amount Billed,” the total charge the provider submitted. It then shows the “Allowed Amount,” the negotiated rate your insurance company agrees to pay. This allowed amount may be less than the billed amount due to contractual agreements. The document also specifies the “Amount Paid by Insurance,” the portion your insurance company directly paid to the provider.
A section of the EOB is “Patient Responsibility,” the amount you are expected to pay. This includes your deductible, the sum you must pay for covered services before insurance begins to pay. It also includes a copayment (a fixed amount) or coinsurance (a percentage of the cost after meeting your deductible). The EOB also lists “Reason Codes” or remarks explaining adjustments, denials, or why services were not covered (e.g., “service not covered” or “deductible not met”). Understanding these components helps track healthcare costs and identify potential billing discrepancies.
Accessing Your Explanation of Benefits
Most health insurance companies provide secure online member portals to access your Explanation of Benefits documents. After logging in with your member ID and password, navigate to a “Claims” or “EOB” section to view and download statements. Many portals also offer electronic notifications via email or text when a new EOB is available. This digital access allows for quick review and record-keeping.
Insurance companies send EOBs via postal mail after a claim has been processed. This mailing occurs within a few weeks after you receive medical services. If you prefer paper copies or do not use online portals, you should expect to receive these documents regularly.
You can also request an EOB directly from your insurance company by calling their customer service line, found on your insurance card or the EOB itself. When calling, provide your policy number, the patient’s name, and the date of service. While your healthcare provider’s billing department can offer limited information, your insurance company is the primary source for a complete EOB. Some EOBs are available online within 48 hours of a claim being finalized, with mailed copies taking 7-10 business days to arrive.
Addressing Issues with Your Explanation of Benefits
If you do not receive an EOB for a medical service within four to six weeks, contact your insurance company. A delay in processing the claim or provider submission may be the cause. Contacting your insurer can help determine the claim’s status.
Reviewing your EOB for discrepancies or errors ensures accurate billing. Look for incorrect dates of service, services you did not receive, or charges that do not align with your expectations. If an error appears to originate from the healthcare provider (e.g., incorrect CPT code or duplicate charge), first contact their billing department to clarify. Requesting an itemized bill can assist this review.
When the error seems to be with the insurance company’s processing, or if you disagree with their coverage decision, contact your insurance company directly. Have your EOB and any relevant medical records ready when you call.
If a service is denied coverage, you have the right to appeal the decision. Insurance companies allow a period, 180 days from the denial notice, to file an internal appeal. The insurer has 30 to 60 days to review an internal appeal, depending on whether the services have already been received. If the internal appeal is unsuccessful, you may have the option to request an external review by an independent third party.