If you receive an EOB, an Explanation of Benefits, it likely means you have filed a claim with your health insurance carrier. The purpose of an EOB is to confirm and explain the health care services and/or treatments you received, how much is covered by insurance, and how much you have to pay – if anything.
This sounds relatively straight forward, but of course, we all know it is nothing of the sort. EOB’s are famously difficult to navigate.
While doing a little homework on this subject over the past week, we have discovered that there is no one system that works better than another; all the carriers have their own approaches. When you get a minute or two to yourself, go online and search out your particular insurance company’s EOB format. There is a good chance you will find a summary of how the EOB is set up and a detailed explanation (with bullets and numbered boxes and arrows and highlights) that will help you get through the thing. There should also be a customer service contact for you – be sure you have your ID and claim number handy should you have to call them.
- Name of main person or subscriber for the health insurance policy – may or may not be the patient.
- Member ID: unique customer number assigned to member.
- Product: the name of the member’s plan.
- Group name: the name of the plan sponsor.
- Group number: the group number for the plan sponsor.
- Patient name: first and last name of patient.
- Patient account: a unique number supplied and used by the doctor, hospital or other care provider.
- Patient ID: often, a social security number, but not always.
- Relation: relationship of patient to member.
- PL (Place): Industry standard code, identifying the location where health care services were provided.
- Service Code: the procedure code that identifies the service performed.
- Type of service: a general description of the service(s) the patient received.
- Service Date: the date(s) the patient received a health care service from that provider or facility.
- Num Svcs: the number of services, procedures, days, units and so on.
- Diag: Diagnosis code associated with service(s) performed
- Claim ID: An identifying number assigned to a claim; often associated with the date of the service.
- Network ID: Identifying number and name assigned to a provider network, if used.
- Amount charged, submitted charges: The dollar amount submitted by your provider to the insurance company for the health care service or treatment.
- Amount allowed; negotiated amount: The dollar amount your insurance company allows for each service billed; when a doctor/hospital or other practitioner is part of a network, the rate negotiated for these services.
- Deductible: Based on the claim, your plan network and the specific services provided, an amount applied to your plan deductible.
- Co-pay amount: the amount you or the patient must pay for the service after the deductible has been applied. A fixed dollar amount.
- Co-insurance amount: The portion of the charge, in addition to any copays or deductibles, that you or the patient must pay for the service provided. A percentage of the allowed amount.
- Patient Responsibility/Member Responsibility: The amount you or the patient owes – for co-pays, coinsurance, deductibles and any amount to the provider not covered. This amount is payable to the provider, not the health insurance company (even though, of course, the insurance company has sent the EOB!)
- Amount Paid, Check Amount, Issued Amount: All of these refer to the dollar amount paid to the provider by the insurance company. If there are charges for you to pay that same provider, the amount you owe will be indicated on the EOB, but that bill will come, separately, from the provider.
- P/P/P – Remember the three P’s: Patient – that’s you or a family member; Provider – the doctor, hospital or other heath care facility that took care of the patient or provided the treatment; Payer – your health insurance company.
- Remarks/Notes: Explanations of pending or denied claims or messages that describe how your claim was processed – sometimes in footnotes.