What Does EOB Mean? It’s Not a Medical Bill

An Explanation of Benefits (EOB) is a statement issued by your health insurance company after you have received medical care and a claim has been processed. It serves as a detailed summary, explaining how your insurance plan has applied your benefits to the services you received. It is important to understand that an EOB is not a bill.

Understanding Your Explanation of Benefits (EOB)

This document functions as a detailed breakdown of the medical services provided, their associated costs, and how your insurance company has processed the claim according to your plan’s terms. Reviewing your EOB helps you track healthcare expenses and identify potential billing discrepancies. It also provides insights into how your health plan covers medical care and contributes to understanding your out-of-pocket costs.

Key Components of an EOB

An EOB typically includes several important sections that detail the claim’s processing. It will list the Service Date and the Provider Name. The Billed Amount or Charges represent the total amount the provider submitted for the services. A separate figure, the Allowed Amount or Approved Amount, signifies the maximum amount your insurance plan will pay for a covered service, often reflecting a negotiated rate between the insurer and in-network providers.

The EOB details how your financial responsibility is calculated. The Deductible is the amount you must pay out-of-pocket for covered services before your insurance begins to pay. A Copayment (Copay) is a fixed amount you pay for a specific covered health service, such as a doctor’s visit or prescription. Coinsurance represents your share of the costs for a covered service, calculated as a percentage of the allowed amount after your deductible has been met. The document also shows the Amount Paid by Plan or Benefits Paid, which is the portion your insurance company covered. The Patient Responsibility or Amount You Owe indicates the remaining sum you are responsible for paying after the insurance has processed the claim. EOBs may also include Reason Codes, which are brief explanations for adjustments or denials of specific charges.

EOB vs. Medical Bill: What’s the Difference?

An EOB originates from your health insurance company and serves as an informational statement explaining how a claim was processed. It outlines what your insurance covers and what portion may be your responsibility, but it is not a direct request for payment. Conversely, a medical bill is a formal invoice sent by the healthcare provider or facility. This document is a direct request for payment for the services you received. It is advisable to review your EOB before paying any medical bill to ensure the charges align and prevent potential overpayments.

What to Do After Receiving Your EOB

Upon receiving your EOB, review it carefully for accuracy. Compare the dates of service, the types of services received, and the provider listed against your personal records. Once you receive a medical bill from your healthcare provider, cross-reference the “patient responsibility” amount on the bill with the amount stated on your EOB to confirm they match.

Identifying discrepancies is important. Look for services you did not receive, incorrect dates, duplicate charges, or charges that do not align with your expectations. If you find an error, such as a possible billing or coding mistake, contact your healthcare provider’s billing department to clarify the charges and request an itemized bill if needed. For questions or to dispute a decision, contact your insurance company using the customer service number on your EOB. Be prepared to understand the appeal process, which typically involves submitting a written appeal within a specified timeframe, often around 180 days from the denial notice, and keep thorough records of all communications, including dates, names of representatives, and any reference numbers, to support your efforts.