An EOB is your insurance company's "Explanation of Benefits" -- what they paid and why.
An EOB, or "Explanation of Benefits," is a document your insurance company mails to you after processing a claim for medical or dental benefits. As they all state somewhere on the form, EOBs are not bills, but may provide information as to any balance you might owe a provider. If any part of any EOB appears to be in error -- a procedure, the date of service, what you might have been told the procedure would cost -- contact your insurance company immediately at the number provided on the EOB. The misinformation might be a clerical error, or it might indicate identity theft.
Instructions
1. Confirm that the member name and address section are correct. If the statement has been forwarded to you because you have not notified your insurance company of your new address, call the company to do so with the telephone number provided on the form.
2. Confirm that the patient's name is correct if he or she is a member of your family covered under your family plan. Some procedures or tests are considered preventative care and are offered for free or at a lower cost by some insurance companies, depending upon the age and sex of the patient.
3. Review and confirm the date of service, the provider and the charge for the service. The charge is what the doctor, hospital, laboratory or other provider billed your insurance.
4. Review any amounts in the excluded columns such as required deductibles, co-payments, or amounts above the area's "usual, reasonable and customary" (URC) fees charged for a given service. Based upon hundreds of thousands of submitted bills, your insurance company maintains a database of what health-care providers generally charge in a given area for a procedure. Deep in your insurance policy contract is a clause telling you that the company is not required to pay for charges that exceed your area's URC rates. Double-check, too, any excluded deductible amounts if you think you might be approaching your out-of-pocket deductible limit. The remaining sum is what your insurance company considers your "covered charge."
5. Review the benefit amount, depending upon your policy, that is applied to the covered charge. For instance, your policy may pay for 100 percent of the covered charges or 75 percent.
6. Find and confirm the "Estimated Member Responsibility" or the "Amount You May Owe Provider." If this amount differs from any bill you have already received from the provider, contact your insurance company for clarification using the number they provide you on the EOB.
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