How to read your Explanation of Benefits (EOB)

Back

We hope to help you to understand how to read your Explanation of Benefits (EOB).  If you will, consider each section as having an individual purpose -- from identifying the members, to identifying the provider, and to how the claim was processed. 

Section 1: Med-Pay's Identification, including our physical and mailing addresses, phone numbers, and fax number.

Section 2: Employer's Group Information.  Employee and patient information, including ID number, date of birth for both the employee and the patient, and relationship status of the patient to the employee (self, spouse, child).

Section 3:  Claim Number which is an internal number assigned by Med-Pay for reference purposes, and the check number if a check is generated (either to the insured or to the provider).

Section 4:  Provider Identification, including the federal tax ID number, address, and the attending physician's name.

Section 5:  Member Specific Claim Information, with columns that show the in-network and out-of-network deductible, co-insurance/copay data for the family and the patient.

Section 6:  Claim Specific Information, including the date the claim was received at Med-Pay with the total billed amount; the date the claim was processed with the amount paid; and if the claim was processed as in-network or out-of-network.

Section 7:  Patient Responsibility showing how much the member must pay on the claim; and how much of a discount was obtained from the provider.  This discount amount is to be written off by the provider.  You are not to pay this discount.

Section 8:  Comments which provide information pertinent to the claim, including exclusions, discounts, etc.  Be sure to review this section as it provides an explanation that will help you to understand your EOB.  See Section 10.

Section 9:  Itemization of Claim Processed, where the columns show the following for each service provided: a CPT code which identifies the service provided, dates of service, billed amount, discount amount, ineligible amount taken, deductible applied, coinsurance amount, copay amount, and coordination of benefits amount taken (if any for each line item), and finally the amount paid for each service line item.  It then shows the Total for the columns.

Section 10: VERY IMPORTANT INFORMATION regarding the claim and your rights and responsibilities to appeal any part of the claim.  There is a time limit that you must adhere to or you may lose your right to appeal. Detailed information is in your plan document.  Please be sure to review it.

Section 11: This will either be a check or an statement of the payment (if any).  It will show the applicable identifying information of the provider, the plan, the claim number, and the amount paid (if any).  Again, if no benefits are due or there is a reduced payment, you should review the "Comments" section (Section 8) for the reason.  See also Section 10.