What your Explanation of Benefits (EOB) tells you.

An Explanation of Benefits (EOB) is simply a statement detailing your medical benefits account activity. Whenever you or a covered family member receive health care services from a doctor, specialist, hospital or other facility, an EOB with complete information about the service provided and charges paid will be sent to you.

Remember to save your EOBs for tax purposes and as a record of family care dates and services.

To understand your EOB, first check to see if you have your statement when you went to the doctor that matches the date of service on the EOB.

1. Indicates the name of the health plan and where your claim was processed.
   
   
2. THIS IS NOT A BILL is simply a statement of benefits received. Below that is the phone number to call if you have questions.
   
   
3. Employee information includes the name of the enrollee, patient’s name and Social Security Number of the employee covered by the plan. The group name and group number in this section should match what’s printed on your EBA&M HealthCare ID card. The claim number is a unique number we assign to each claim. The patient number is supplied by the provider of services. Date is the date that the check was printed, not the date the care was received.
   
   
4. Payment Summary Section should match what is detailed below.
   
   
5. Provider is the name of the health care provider who submitted the claim. The provider may be a doctor, specialist, hospital, lab, clinic or other medical facility.
   
   
6. Service Date(s) is the actual date(s) the patient received health care services from the provider.
   
   
7. Service Code describes the type of service(s) the patient received from the provider. A description of this code is found in box 20.
   
   
8. Total Charges are the total reasonable and customary fee that the provider’s charge to provide the type of service received.
   
   
9. Ineligible references any portion of the total charges ineligible for payment under your HealthCare benefits plan. For example, Services not covered by your plan or services exceeding the maximum allowable reimbursement are not covered. Your provider may bill you for these charges.
   
   
10. Reason Code is an explanation of a remark code and tells you how your claim payment was adjusted. A description of this code is found in box 21.
    
    
11. Discount Amount is the contracted fee discounts the provider has agreed to accept. You are not responsible for this amount.
    
    
12. Covered By Plan is the portion of the submitted charges that is eligible for coverage under your benefit plan.
    
    
13. Deductible Amount is the portion of the submitted charges that is not payable because it’s being applied to your annual deductible, your plan covers a percentage of eligible charges.
    
    
14. Co-Pay Amount is the amount the patient is responsible for paying at the time of service to the provider for services rendered.
    
    
15. Co-Insurance is the amount the patient must pay after the plan has paid its share. For example: Your plan may pay 80% for covered services and require you to pay the remaining 20% as coinsurance.
    
    
16. Paid At is the percentage of the balance covered by your particular benefit plan. For example: If your plan requires that you pay a 20% coinsurance amount for covered health care services, the eligible portion of your claim will be “paid at” 80%.
    
    
17. Payment Amount is the total amount we paid to the provider or insured. This will also include the patient responsibility amount. The patient responsibility amount you may owe the provider if your plan did not pay all the charges. But remember that your EOB is not a bill. Don’t send your payment unless you receive a bill directly from the provider. If you are billed for more than this amount, ask the provider for a detailed explanation.
    
    
18. Payment to: indicates the total amount the plan paid to the provider or insured, including the check number.
    
    
19. Service Codes description: these codes describe the type of service provided.
    
    
20. Reason Codes description: these codes explain any reductions made to a charge.
    
    
21. Messages: we may add messages in this area to help explain how a claim was processed.
    
    
22. Rights of Review and Appeal explains what to do if you disagree with the way your claim was processed and would like to request a formal review.