How to Read an Explanation of Benefits
Most people who have health insurance have become accustomed to receiving an Explanation of Benefits (or “EOB”) after a provider visit. Usually prominently marked “This is not a bill,” the EOB explains how your insurance will cover the visit and what you’ll be expected to pay. To reduce some complication, we’ve listed and defined a few of the terms you’ll typically see on your EOB. However, please note: Different insurers use different terms for some items, and EOBs from different insurers might look dramatically different. Still, getting a basic understanding of these terms should help you decipher your EOB and better track your healthcare costs.
• Insured or Enrollee: This is the name of the person who has the coverage through an employer or private plan.
• ID Numbers: The EOB likely will include a variety of numbers referring to the insured person and the benefit plan. These might be listed under descriptions including “Group Number,” “Participant Number” or simply “ID Number.” All of these should match up with the numbers on your insurance card and/or on the provider bill. If any numbers don’t match up, call your provider or insurer to get clarification.
• Claimant: This is the person who received care.
• Claim Number or Control Number: A unique identification number assigned to this claim.
• Service Dates: The date care was received.
• Provider: The caregiver billing for care.
• Services: Care received. (sometimes this will be a code or an abbreviation)
• Provider Charge/Total Charge: The price the provider has set for the care received.
• Allowed Charge/Negotiated Amount: The price your insurer has negotiated for care.
• Covered: The amount that will be covered by insurance. (this takes into account deductibles)
• Charges not covered: Any amounts not eligible for coverage.
• “Payable at …”: If you have a percentage deductible, this will tell you the percentage of coverage.
• Remarks: Often a code or statement that explains how the claim was covered.
• Summary of Payment or Payment Details: The amount paid and who received the payment.
• Contact Information: The address and phone number you should contact with questions.
As you wade through these forms, be sure to compare your EOB to your actual bill and make sure the information – and especially the costs – line up. If not, call your provider and insurer to verify that you’re paying the right amount.
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