Explanation of Benefits (EOB)

Most of us have seen an explanation of benefits or EOB, but what does it mean?

After you've visited a doctor, clinic, or hospital, an EOB from the insurance administrator tells you and your provider what portion of the provider's charges are eligible for benefits under your insurance plan.

The EOB is the result of the claims process. To better understand your EOB, let's look at the steps in the claims process.

If your provider is part of a provider network, and you have an insurance plan using this network, the provider usually sends your bill to the network to have the network discount calculated. (This discount may reduce your out-of-pocket expense!) The network sends the claim to your insurance administrator.

If your provider is not in a network, the provider may send the bill to you or your insurance company. If you're sent the bill, you'll submit the claim to your insurance administrator.

Your insurance administrator reviews the claim to determine your benefits. If another insurance company is involved, the insurance companies coordinate benefits to determine which plan is reponsible for the charges.

Your health insurance administrator sends you and your provider an EOB, and, when appropriate, your provider also receives a check. Your EOB may identify:

The patient and the service provided.

The amount charged by the provider.

The amount of the network discount (when appropriate).

The amount of the charges that are covered and not covered under your plan.

The amount paid to your provider.

The amount you're responsible for.

The provider may bill you for charges that aren't covered by your insurance plan, including:

Amounts you need to satisfy, such as a deductible, before your insurance benefits begin.

Charges for procedures that aren't covered under your plan.

Charges that are more than what's usually charged by providers in your area for the same service.

Remember, the EOB is not a bill, but it explains what was covered by insurance. The provider may bill you separately for any charges you're still responsible for.

If you have questions about the claims process, call your insurance administrator or your agent.

Information provided by American Medical Security, Inc. which markets insurance products underwritten by United Wisconsin Life Insurance Company.