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Explanation Of Benefits

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After an insurer processes a claim, it sends you an Explanation of Benefits ("EOB") -- even if the insurer decides not to pay the claim.

EOBs usually contain identifying information, processing details and information about the amount that was billed, the amount the insurer paid, and the amount left for you or another insurer to pay. Medicare and each private insurer have their own EOB form. 

An EOB should arrive within four to six weeks after a charge is incurred. The arrival time can vary depending on how quickly the provider bills the insurer and whether the information is complete in the first filing. 

While Medicare and each private insurer have their own EOB form, EOBs usually contain the following:

identifying information included in an EOB: 

  • Your name
  • The patient's name if different.
  • The insurance ID number (frequently your Social Security number).
  • The group number if your coverage is part of a group plan.
  • A claim number.
  • The date the claim was processed

Processing details included in an EOB: 

Usually in a box or boxes across the page will be:

  • Name of the doctor or other health care provider.
  • Date of service: The date you incurred the charge.
  • Type of service: The type, in very general terms, of medical service that was provided, such as an office visit, laboratory test, or just "health service."
  • Total billed: The amount the doctor or other health care provider charged.
  • Amount covered: The amount upon which the provider will base reimbursement. This can be less that the amount billed if the amount billed is more than the "usual, customary, reasonable" charge the insurance company uses. If the claim is being denied, the amount will be zero. NOTE: Some companies will instead show the "Amount Not Allowed." If this happens, subtract this amount from the total billed to get the "covered charge."
  • Explanation code: If the entire bill is not covered, there will often be a code explaining why. The legend for theses codes will usually be on the bottom or back of the EOB. Explanation code: will often refer to the following explanations:
    • Amount billed exceeds Usual, Reasonable & Customary: Insurance companies generally do not pay a claim in excess of what they consider to be the Usual Customary and Reasonable charge for the service.
    • Duplicate charge: This happens frequently. The physician bills the carrier, then, not having received a payment, re-bills the carrier. Usually, it means the original bill is still being processed.
    • This exceeds the allowed charge for a participating provider. You are not responsible for the excess amount: This means that the physician was a PPO provider, but billed for more than permitted under the PPO contract. Here the insurance company is saying that it won't pay the bill because of the PPO contract. For the same reason, you don't have to pay the amount either.
    • Applied to Deductible: If your deductible hasn't been satisfied, the covered charges will be applied toward it until it is.
    • Co-Insurance: This is the amount you are obligated to pay under the insurance contract. For example, if your policy has 80% coinsurance, 20% of the covered charges will appear in this column.
    • Insurance Company Payment: The amount the insurance company has paid and to whom it has been paid.


If you have questions about or do not agree with the EOB, contact the insurance company.  There will usually be a toll-free number on the bill. For information about how to question an EOB, click here.

NOTE: If you do not agree with charges the insurer does not pay, you have a right to appeal the denial. To learn how, click here.

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Explanation of Benefits

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