EOB-type form with several charges listed
An Explanation of Benefits (EOB) form is an itemized summary of services that informs consumers of recent health insurance claims. The EOB lets consumers know what the provider has billed the insurance company, how much of that cost was covered and how much the consumer might need to pay. Although insurers might organize their EOBs differently, the content is fairly uniform. Information listed on the form usually includes a claim summary, payment summary and claim details.
Instructions
1. Find the Claim Summary section on the EOB.
The subscriber is the primary person eligible for benefits. The patient, who is receiving the services, can be the subscriber or a dependent. The group name and number identify the specific plan under which the subscriber is covered.
Each service or visit has its own unique claim number to help with tracking of the individual claim. The provider is where, or from whom, the services were rendered (e.g. name of doctor, clinic or laboratory). Covered medical supplies are also included on EOB forms.
2. Find the payment summary section.
Dollar amounts are listed for charges submitted to the insurance company and for out-of-pocket costs. Examples of out-of-pocket costs include the deductible, coinsurance and copay, all of which are also known as the patient responsibility.
The deductible is the amount of money a consumer needs to spend before the insurance company starts paying benefits. (Example: The deductible for Mary's plan is $300 per year. Mary needs to spend $300 of her own money before the insurance will start paying for other covered services).
The copay is a flat fee designated by the insurance company that the patient pays for certain services, such as office visits or prescriptions.
The coinsurance amount includes charges for services not covered at 100 percent. The patient responsibility (coinsurance, copays, or deductible amounts) is the amount a provider may bill the patient after all payments and deductions are made on the claim. Payment would be made directly to the provider, not through the insurance company.
3. Find the Claim Details section.
Each claim has a corresponding type and place of service, as well as a specific date when the service was provided.
The amount a provider billed to the insurance company is often known as the charged amount. Each insurance company also has an allowed amount, which is the maximum they will pay for a particular service. (Example: the clinic billed $100 for a standard office visit, but the insurance company only pays up to $75 for that type of service).
Some insurance companies also list the percentage covered for that type of service. (Example: X-rays covered at 100 percent, and wheelchair rental at 80 percent. The insurance company pays the provider 100 percent of the x-ray charge and for most, but not all, of the wheelchair rental charge).
Tags: insurance company, amount provider, before insurance, billed insurance, billed insurance company
