Understanding the Explanation of Benefits
If you’ve been to the doctor or the ER recently and used your health insurance to help pay for the treatment, then you can expect to receive an Explanation of Benefits in the mail soon. But, what is this document, what should you do when you get it, and why is it important?
What is an Explanation of Benefits?
Simply put, an Explanation of Benefits (EOB), is a notification to let you know when your health care benefits claim has been processed by your insurance company.
It’s important to understand that an explanation of benefits is not a health care bill. The EOB will detail the expenses that were submitted by the healthcare provider (doctor, hospital, ER, urgent care center, etc.) and lets you know how the claim was processed.
What Information Does Your EOB Include?
There is no standard format for an explanation of benefits, however, most include three main sections:
- Total of Claim or Claims: Your EOB might contain more than one claim. The notification will highlight all the financial information about each claim, including:
- Total Amount Billed by the Healthcare Provider
- Total Benefits Approved by the Insurance Company Based on Your Plan Coverage
- Any Amount Owed to the Healthcare Provider
- Service Detail: Here you will find a list of all the services you or your dependent received from the healthcare provider. This section should include:
- The Name of the Doctor or Facility You Attended
- Date of Services
- Date of Charges – Both Billed and Allowed
Some Insurance Companies Display any Additional Savings that Your Plan Provides Such as Provider Discounts and Other Deductions
Summary: This Will Show You a Clear Picture of Your Deductible, Copays, And Health Spending Accounts if Applicable.
Additional information regarding amounts not covered, and out-of-pocket expenses might also be included.
What Should You Do When You Receive an EOB?
Your explanation of benefits is an essential record of claims for any medical services and benefit coverage, and you should hold on to it for at least 18 months, preferably two years in case any questions or disputes arise from about your claim or your bill.
What Do You Need to Check on Your Explanation of Benefits?
When you first receive your EOB, you should carefully check the information it contains, and pay close attention to the following:
- Make sure your personal information is correct if not, it could be a simple mistake, but in the worst-case scenario it could be someone trying to use your identity
- Ensure you are not being billed for a service you did not receive. If your EOB contains more than one claim, make sure you are not being charged twice for the same service.
- Make sure which doctor or health care provider submitted the claim and cross check it with your records to make sure there are no mistakes.
What Happens if the Insurance Company Doesn’t Pay the Whole Amount?
If your healthcare plan doesn’t cover the whole amount of the services you received, then the health care provider will send you a bill for the amount owed.
You do not have to pay anything until you receive the bill, and never pay more than the amount the explanation of benefits says you owe. If you are billed more than what the EOB says, you should contact your insurance company immediately, so they can investigate this matter.
If your insurance company didn’t pay anything, find out why, it could be that you have not met your annual deductible, but, it could also be a mistake on their part, if that is the case you need to submit an appeal.
Altus Emergency Centers has focused its efforts on helping people better understand their insurance plans and how our billing works. If you have any questions regarding your billing, please don’t hesitate to call our Patient Advocate Department, it will be our pleasure to assist you.
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