Making Sense of Your EOB
When your insurance company processes your claim, they will send you an explanation of benefits (EOB) detailing what procedures they covered and paid. The most important thing to know about the EOB is that this is NOT a bill.
While the information, terminology and organization of an EOB varies greatly from one insurance company to another, most of them will have these sections and information.
The EOB may state that you could be responsible for costs not covered by insurance. We ONLY charge you the normal co-payment, co-insurance, or deductible required by your insurance policy — the same amount you would have paid if you had gone to any other emergency room.
- Your name or the insured person’s name and address.
- Your insurance information, such as member ID, group ID and group name.
- Details about who the patient was, when services were received, what type of services they were, claim information, and provider information.
- Details about the services you received, including but not limited to: the date services were provided, the amount your insurance company paid the health care provider for those services, any discounts or reductions granted by the insurance company, your deductible and co-payments amounts, and any amounts not covered by insurance.
- The total amount of benefits in the claim.
- The total amount your insurance company is responsible for paying.
- The total of how much you MAY owe, including your co-payments, deductibles, co-insurance, and any amounts not covered by insurance.
The EOB may also include year-to-date totals for your deductibles and co-insurance.
Glossary of Terms
Subscriber Information — Identification information about the policyholder, usually their member ID, group ID, and group name.
Place of Service — Outpatient is used for services received in an emergency room or clinic and that did not require hospitalization. Inpatient is used if the patient was admitted to a hospital.
Provider — The health care organization or facility where the patient received medical treatment.
Payment to — The entity to which the insurance company has sent payment for the listed services.
Total Charges — The amount billed to insurance for the services provided by the physician, pharmacy, hospital, laboratory, or other health care professionals and received by the patient.
Other Insurance — The amount paid by any additional health insurance plans covering the patient, such as Medicare.
Amount Paid — The total amount paid by the insurance company to the physician, pharmacy, hospital, laboratory, or other health care professionals for the listed services received by the patient.
Notes — Extra information or explanation about a listed payment or amount.
Non-Covered Charges — Any charges in excess of amounts covered by the insurance policy in addition to regular co-payments, co-insurance, and deductibles.
Deductible — The amount the policyholder must pay before the insurance company pays. Only covered health expenses count toward a deductible.
Co-insurance — The portion of the allowable charges the policyholder is responsible for, usually as a percentage. The insurance company is responsible for the other percentage of charges.
Co-pay — A flat fee the policyholder is responsible for paying for services as defined by their insurance policy.
Total Patient Responsibility — The total amount that the policyholder must pay for the listed services.