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How to understand an EOB

Aug 2, 2018 2:37:08 PM / by Tamara Castellano

First, it would probably be helpful if I explained what EOB stands for.  EOB is short for Explanation of Benefits.  You may also see it described as Explanation of Medical Benefits, but it is universally referred to as an EOB.

An EOB is simply an explanation of how a medical treatment or service you received has been paid.  It is not a bill.  That’s worth repeating…it is not a bill so don’t panic when you see the amounts that were billed.  But, let’s be clear, there is nothing simple about an EOB.  There are different codes, amounts, adjustments and more acronyms (I refer you to our blog article about learning to speak insurance).

Here is how to understand an EOB like a pro.

It is not a bill

The next time you get an EOB, there is no need to panic.  The amount charged for a service is not what you pay.  If there is an amount you owe, you will receive a bill from the provider / hospital / lab. 

The top half of your EOB

In the top part of the EOB, you’ll find the name of your insurance company (UPREHS) and contact information, your contact information, including your member number and a payment summary.

Top of EOB

 

Understanding the chart

This is the meat of an EOB and outlines the total amount charged, what has been paid (or not paid), etc., and it’s worth explaining line-by-line, column-by-column. 

Claim information.  The information in the top of the chart is straightforward.  It includes the claim number UPREHS has assigned, your member number, the name of the patient, the name of the provider and a patient ID.  The patient ID is the account number from your provider.

Amount charged.  Again, this is the total amount the provider has billed UPREHS for a service or treatment.

Ineligible amount.  In some cases, there may be two reasons why all—or part—of an amount charged is ineligible.  Thus, there are two columns titled ineligible amount.  Regardless of the reason for an ineligible amount, there will always be a code next to the amount that is ineligible.  The code—and there are dozens of them—will be explained just below the chart.

Chart of EOB

Copay / Coins.  You’ve probably figured out that this means copayment / coinsurance.  This is the amount you pay, per the requirements of your plan.

Deductible amount.  Some UPREHS plans have deductibles, others do not.  Depending on the plan you’re enrolled in, this may or may not apply to you.  If you are enrolled in a plan that has an annual deductible, what you have paid toward that is listed in this column.

Provider adjustment.  An adjustment to your charges made by your provider.

COB amount.  Again, welcome to the world of acronyms. COB stands for Coordination of Benefits.  In english, that is a scenario in which two insurance companies share—or coordinate—the payment of your benefits.

Pay %.  Of all the lines on a COB, this is probably the most confusing.  If the amount charged is $1000, and the pay % is 100% but the total amount paid is $22, that math doesn’t add up.  But here is why it’s confusing.  The pay % is the amount that is paid AFTER all of the aforementioned adjustments and amounts are taken off.  The pay % refers to the amount that is paid of the adjusted total.

Amount paid.  The amount paid is what the insurance company pays after all of the adjustments are taken off the amount charged.

The bottom half of your EOB

The bottom part of your EOB explains your right to appeal a decision about what was paid—or denied.  It will tell you how many days you have to file an appeal and where to send your appeal.

 

Bottom of EOB

 

An EOB is your way to understand medical billing.  You should always review these carefully and make sure your being billed correctly for service and procedures.  And most importantly, if you have a question or think something is incorrect, never hesitate to call your provider and ask questions.

Topics: Member Resources, Insurance Terms, EOB

Tamara Castellano

Written by Tamara Castellano

Tamara is the marketing communications guru for UP Health.

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