Explanation of Benefits: What is it?
You recently visited the doctor. You showed them your insurance card, paid your visit copay, and then let them take care of the insurance part. A few weeks later, you receive a document in the mail titled “Explanation of Benefits.” What is this?
An Explanation of Benefits, or EOB, breaks down what your insurance policy is covering for the visit and services you received, as well as what you may owe. In addition, it includes details about your medical visit.
What You’ll Find in Your EOB
- Patient information (information about you)
- Your insurance plan name and description, and your insurance company’s contact phone number (the same information that’s on your member ID card)
- The doctor or medical provider whom you visited, and the date of service
- A claim number (a unique reference number)
- The person who gets reimbursed in case of an overpayment, known as the payee
How Charges are Listed
Provider charges
The total amount your doctor or medical provider charged for the service
Allowed charges
The amount your provider will be paid (which may differ from the provider charges, with you owing the difference)
Paid by insurer
What your insurance plan will pay based on your coverage
Patient balance/patient responsibility
The out-of-pocket amount you still owe after your plan has paid for everything else (not including anything you’ve already paid for your visit, such as your copay)
Remember, the EOB is not a bill. You are not required to make a payment until after you receive the final bill.
How the Claims Process Works
When you visit a medical provider and show your insurance information, the provider submits a claim (a request to pay) to your insurance company on your behalf. The submission of a health insurance claim serves the purpose of informing the insurance company about the medical expenses you’ve incurred and allows them to assess the claim based on the terms and conditions outlined in your policy. Once approved, the insurance company provides reimbursement for the covered expenses or directly pays the healthcare provider, helping you manage the financial impact of your medical care.
At the conclusion of the claims process, and after receiving your Explanation of Benefits, you will receive the final bill for services minus what your insurance plan covered. Your bill should never be higher than what is listed as the patient’s responsibility. It may take several weeks to months to receive the final bill, due to the multiple steps involved in the claims process.
What if something looks incorrect in my Explanation of Benefits, or the amount on my bill doesn’t match?
First, you should gather all documents related to your visit, including the visit summary, Explanation of Benefits, and your bill. Keep in mind that you may receive multiple bills and EOBs related to your recent medical services, especially if you saw more than one provider or specialist during your visit. Compare these documents looking for any differences, duplicate charges, or services that weren’t performed. Be sure to verify that your personal information, policy name, and policy numbers match what’s on your member ID card.
If you disagree with anything, contact your healthcare provider’s office or the insurance company directly. Keep a record of all communications for future reference.
Looking for Insurance Coverage?
Our dedicated team at LEB Insurance Group is ready to help you find the best health plan for your needs, ensuring that your health insurance benefits become a source of empowerment rather than confusion. Contact us today – because your health matters, and so does your peace of mind.
