An Explanation of Benefits, or sometimes referred as an EOB is a document sent by an insurance provider to an enrollee and the enrollee’s healthcare/dental provider. An EOB is produced in response to a claim for services. It contains important information regarding the payment responsibilities of both the insurance company and the patient. An insurance company is required to send an EOB to both the patient and their provider. An EOB includes the following:
1 – Name and mailing address of the member.
2 – Contact information for insurance carrier.
3 – A section that displays when the claim was received and optional messages.
4 – First and last name of patient, relationship to member, members name and Group Name.
5 – Member ID and Group #.
6 – Date and type of Service.
7 – Submitted Charges. The amount billed by the service provider.
8 – Negotiated Amount is the special fee that has been negotiated with an in network provider for a particular service.
9 – Not Allowed/Not Payable by plan is the amount being denied.
10 – This field will let you know there are remarks on bottom, or back of page pertaining to a particular service.
11 – Patients Copay if any for services rendered.
12 – Amount, if any applied towards patient’s deductible.
13 – The amount the insurance carrier benefit is calculated. This is the difference between the negotiated amount and copay.
14 – Paid at is the percentage used to calculate the benefit.
15 – This is the amount the insurance carrier will pay for services.
16 – This may also say “coinsurance”, which is the portion of the allowable charges in which the member is responsible for.
17 – Patient Responsibility indicated the amount for which the patient is responsible for. This includes services that were not covered, deductible, copay and coinsurance amounts.
18 – Summary of plan financials for the benefit year.