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What is an EOB (Explanation of Benefits) and how do you read it?

5 minute read

What is an explanation of benefits?

An Explanation of Benefits, commonly referred to as an EOB is a statement from your health insurance company providing details on payment for a medical service you received. It explains what portion of services were paid by your insurance plan and what part you’re responsible for paying. Your insurance company sends it to you when your health care provider submits a claim on your behalf. When you read your EOB, make sure you understand every line. Use it to track your expenses and make sure there are no billing errors.

When you visit a doctor, dentist, or other health care provider, you will generally be asked whether you want the service to be billed to your insurance. If you do, the medical office should fill out a health insurance claim and submit it to your health insurance company. This is essentially a request for payment to your insurance company to cover the cost of the visit, treatment, or equipment. When the insurance company gets the claim, they will evaluate the claim, create an Explanation of Benefits (sometimes referred to as an EOB) and send it to you in the mail. They might also make a digital copy available through their website. 1

You should receive an EOB whether you have private insurance, insurance through your employer, or Medicare. 2

You should receive an EOB for every service you received, whether you owe anything for the service or not. You will get a separate EOB for each service you received, or a separate EOB for the same service provided on different days. 3

If your health insurance plan is an HMO, you might not receive an EOB, because many HMOs pay a monthly fee for patient care rather than paying for each service separately. 4

An EOB is not a bill

The EOB tells you how much of the doctor’s charges you are responsible for, but it is not a bill. The EOB is for your reference only. Your medical bill for that service will come separately, and it will be sent by your provider, not your insurance company.5 Some providers require up-front payment, in which case you will be reimbursed by the insurance company.

What is included in your EOB?

The EOB contains the following information:

  • Your name, or the name of your dependent (whoever received the service)
  • Your (or your dependent’s) health insurance ID or policy number, and the claim number
  • The name of the health care provider who administered care – doctor, dentist, specialist, laboratory, hospital, or clinic
  • The type of service or equipment you received and the date on which you received it; for service that lasted more than one day, the date range will be given
  • The cost of the service (what your provider billed the insurance company)
  • How much of the billed amount your insurance company paid
  • The remaining amount to be paid, which is usually your responsibility

The EOB might contain information about whether the amount you need to pay will be applied to your deductible. Sometimes an EOB also lists how much is left of your deductible for the year.

Other items that might be included in your EOB include a glossary of terms and definitions, information on how to appeal a claim, further details about the services reflected on the EOB, and language instructions. 6

How to read an EOB

It’s important to read your EOBs as they arrive. Your EOBs help you understand several important aspects of your health care costs.

The EOB helps you find errors. When health insurance claims are completed and filed, errors are sometimes made by humans and computers, and these might be reflected on your EOB. Here are some of the mistakes you might find:

  • Being billed for services you didn’t receive
  • Double billing, such as being billed twice for lab tests
  • The provider billed the wrong amount for a service
  • Your insurance company didn’t cover a service they should have, according to your plan
  • Incorrect dates of service
  • An error with your deductible

The EOB helps Identify potential medical fraud. If your EOB lists services you didn’t receive, it’s possible your provider is billing fraudulently. This might point to medical identity theft, medical fraud, or Medicare fraud. 7

The EOB tells you how much you owe. Your EOB includes how much you owe. It is not a bill, which you will get separately from your provider. The amount you owe that’s listed on your bill should match the amount you owe listed on your EOB. If you haven’t received your bill or paid your provider yet, you can plan for making your future payment when you get your EOB.

The EOB helps track medical care and costs. Your EOBs list all the medical services and equipment you received throughout the year and how much they cost. The only exception to this is medical service that is not billed to your insurance company. Keep your EOBs so that you’ll have a record of what care you received, how much you were charged for that care, and what your health plan covered of those charges.

What to do if you find errors on your EOB

Errors on your EOB that are not corrected could lead to long-term financial difficulties. 8

If your EOB contains any kind of mistake, or if you suspect that it does, you should call your health insurance company, your health care provider, or both. Don’t be shy about going over every line with each of these offices. Your financial and medical well-being are worth the effort.

Sources:
1Elmblad, Shelley. October 30, 2018. “Understanding an Explanation of Benefits (EOB) Statement.” The Balance
https://www.thebalance.com/what-is-an-explanation-of-benefits-1293685
2Bihari, Michael. May 18, 2018. “Understanding Your Explanation of Benefits (EOB).” Verywell Health.
https://www.verywellhealth.com/understanding-your-eob-1738641
3 Breher, Barb. August 5, 2017. “What Is an Explanation of Benefits vs. a Bill?” HealthPartners.
https://www.healthpartners.com/hp/healthy-living/healthy-living-blog/explanation-of-benefits-vs-bill.html
4“Your Guide to Health Insurance Paperwork.” WebMD.
https://www.webmd.com/health-insurance/understanding-health-insurance-paperwork#2
5“Understanding Medical Bills.” MB&CC.
https://www.medicalbillingandcoding.org/health-insurance-guide/understanding-medical-bills/
6 “Understanding Your Explanation of Benefits (EOB).” July 2018. Cigna.
https://www.cigna.com/individuals-families/understanding-insurance/explanation-of-benefits
7Bihari, Michael. May 18, 2018. “Understanding Your Explanation of Benefits (EOB).” Verywell Health.
https://www.verywellhealth.com/understanding-your-eob-1738641
8 Bihari, Michael. May 18, 2018. “Understanding Your Explanation of Benefits (EOB).” Verywell Health.
https://www.verywellhealth.com/understanding-your-eob-1738641
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This content is subject to change without notice and offered for informational use only. You are urged to consult with your individual business, financial, legal, tax and/or other advisors and/or medical providers with respect to any information presented. Synchrony and any of its affiliates, including CareCredit,(collectively, "Synchrony") makes no representations or warranties regarding this content and accept no liability for any loss or harm arising from the use of the information provided. Your receipt of this material constitutes your acceptance of these terms and conditions.
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