What Is an EOR Document in Medical Billing?
Demystify your medical Explanation of Remittance (EOR). Understand what this document tells you about your healthcare claims and financial responsibility.
An Explanation of Review (EOR) document in medical billing provides a detailed breakdown of how an insurance claim was processed. It serves as a communication tool from your insurance company, explaining the financial aspects of services you received. Understanding this document can help patients manage healthcare costs and ensure billing accuracy.
Understanding the EOR
The Explanation of Review (EOR) is a document issued by your health insurance company after they have processed a medical claim for services you received. It clarifies how much of a medical claim was paid, adjusted, or denied, helping you understand the financial journey of your medical care.
The EOR explains what your insurance paid, what was discounted, and what portion remains your responsibility. This document is not a bill; instead, it outlines the financial details between your provider, your insurer, and you. Reviewing it helps you track your healthcare expenses and understand your insurance coverage.
Key Information on Your EOR
An EOR document details the processing of your medical claim, containing several key pieces of information. It includes identifying details such as your name, insurance policy number, the healthcare provider’s name, and the dates services were provided.
The document lists the specific services you received, often identified by procedure codes, along with the original amount the provider billed. Your EOR then shows how much your insurance plan covered and paid. Any adjustments or discounts, such as those due to network agreements, will also be detailed.
Finally, the EOR indicates your financial responsibility, which is the amount you may still owe the provider. This amount can include your deductible, co-payment, or co-insurance. A deductible is the amount you must pay out-of-pocket before your insurance begins to pay. Co-payment is a fixed amount you pay for a covered service, while co-insurance is a percentage of the cost of a covered service you pay after you’ve met your deductible.
Interpreting Your EOR
Understanding your EOR involves carefully reviewing each section to reconcile charges and payments. Start by comparing the services listed on your EOR with the services you actually received, paying attention to dates of service and procedure descriptions.
Next, examine the billed charges versus the amount your insurance covered and paid. The EOR will detail any discounts or adjustments made, which can explain why the paid amount is less than the billed amount. This is often due to contracted rates between your insurance company and the provider. Look for explanations if a service was not covered or was only partially paid, as reasons such as “not a covered benefit” or “deductible not met” are provided.
Focus on the section that outlines your patient responsibility, the amount you are expected to pay. This figure combines any applicable deductible, co-payment, or co-insurance amounts. For example, if your plan has a $1,000 deductible and you have not met it yet, the EOR will show that amount as your responsibility until it is satisfied. A co-payment might be $20-$50 for an office visit, while co-insurance could be 10-30% of the allowed cost after your deductible.
Actions After Receiving Your EOR
After receiving and interpreting your EOR, compare it carefully with the medical bill from your healthcare provider. The patient responsibility amount on your EOR should match the amount you are being billed. If these amounts do not align, investigate the discrepancy.
If you identify a difference or have questions about any charges, contact your healthcare provider’s billing department first for clarification. They can explain billing codes or contractual adjustments that may not be immediately clear on the EOR. If the issue remains unresolved, or if you believe there is an error, contact your insurance company directly to discuss the claim.
Maintaining accurate records of all EORs and corresponding medical bills is beneficial for financial planning and any potential disputes. Insurance companies provide a timeframe, typically 60 to 180 days from the date of service, within which you can dispute a claim. Reviewing these documents promptly helps address any issues within these timeframes.