Understanding Your Insurance Carrier’s Explanation of Benefits: How to Read It and What to Do Next

Each time your insurance carrier processes a claim for you, you will receive an Explanation of Benefits (EOB). This is not a bill, but rather an explanation of how your claim was processed.

The Explanation of Benefits will show you the amount that your provider billed, what the insurance carrier will allow for that service, and any amounts that may be your responsibility. If you need specific instruction for your health plan, consider logging into your member portal with the insurance carrier, as more detailed instructions will be found on the insurance carrier website.

Common References on Any Insurance Carrier’s EOB

Each time you receive services from your provider, review your EOB closely and compare it with the receipt you receive from your provider. To help you better understand how to read your Explanation of Benefits here are some of the common items you will find and what these descriptions mean:

• Provider – This is the name of the provider who is billing your insurance company
• Type of Service – The types of services or products that you have received from your provider
• Dates of Service – The date of your visit or appointment
• Amount Billed – The dollar amount your provider has billed to the insurance company
• Allowed Amount – This is the amount that your insurance carrier recognizes as the allowable amount for that service
• Amount Not Covered/Not Allowed Amount – For a contracted provider this is the amount not eligible for payment and should not billed to you
• Deductible – If you have a deductible for certain services this will tell you how much of the service was applied towards your deductible and what your responsibility is. Some EOB’s will also tell you how much of your deductible has been satisfied to date.
• Co-Pay /Coinsurance – If you have a fixed co-pay amount or a coinsurance amount to pay for certain procedures, it will be reflected under this heading
• Amount Paid / Benefit to Provider – this is the insurance carrier’s payment to the provider
• Your Responsibility / Provider May Be Bill You- This can be a combination of copayments, deductibles and coinsurance

Comparing Your Billing Statement with Your Explanation of Benefits

You may find that your provider is billing you for services that have not yet been processed by your insurance carrier, so be sure to play close attention to the items the provider bills and check to see if your insurance carrier has processed the claim for that date of service.

In short, determine if the billed amounts the doctor is sending you match with what is being sent to the insurance carrier.

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For more information about your claims, you can access all your information once you have registered with your insurance provider.