Explanation of Benefits
Explanation of Benefits or EOB is the detailed statement of the carrier’s determination of the claims processed. The determination can result in a payment or a denial.
The Explanation of Benefits contains the following information:
Name of the payer, Name of the provider, Pay-to address, Name of the patient, Name of the member, his id #, date of service, procedure code, amount billed by the provider, amount allowed by the payer, co-insurance, deductible, amount paid by the payer. The amount paid by the payer is equal to the amount shown by the check.
What exactly is the EOB, I mean, what do the letters stand for.
Simple: EOB is short for Explanation of Benefits which is a notification sent by the medical insurance company administrators after processing a medial insurance claim.
The EOB explains the total amount the health care provider billed for medical services, the amount paid under the insurance contract, and who was paid. Patients should keep a copy of their bills from the health care provider of medical services to compare them to the EOB.
Below is a description of your Explanation of Benefits (EOB). The numbers correspond with the numbers on the sample copy of the EOB (see the last page for an example of an EOB).
1. Claim Processing Office: this is the location of the claims processing office. You can write to customer service at this location.
2. Address: the name and address where the EOB is being mailed.
3. Customer Service: number to call with questions regarding your claim.
4. Group Name: the name of your Group (in most cases, this is your employer).
5. Group Number: the identification number for your Group. Please refer to this number if you call or write about your claim.
6. Location Number: the number assigned to your location within the Group.
7. Location Name: the name or description of the location.
8. Enrollee: the name of the covered employee.
9. Enrollee ID: employee’s social security number (last 4 digits only) or identification number. Refer to this ID number if you call or write about your claim.
10. Plan Number: the identification number for your plan of benefits.
11. Paid Date: if a check was issued, the date it was issued.
12. Fraud Statement: if the services shown are incorrect, contact HealthSmart immediately.
13. Claim Number: the unique identification number assigned to this claim. Please refer to this number if you call or write about this claim.
14. Patient: the name of the individual for whom services were rendered or supplies were furnished.
15. Patient Acct: number assigned by the service provider.
16. Provider: the name of the person or organization who rendered the service or provided the medical supplies.
17. Dates of Service: the date(s) on which services were rendered.
18. Procedure Code: the Current Procedural Terminology (CPT) codes listed on the provider’s bill.
19. Amount Billed: the charge for each service.
20. Charges Not Covered: charge that is not eligible for benefits under the plan.
21. Remark Code: code relating to the “Charges Not Covered” amount. Also used to request additional information or provide further explanations of the claim payment.
22. Discount Amount: identifies the savings received from a Preferred Provider Organization (PPO), if applicable.
23. Discount Code: the corresponding code for negotiated savings.
24. Allowed Amount: maximum allowed charge as determined by your benefit plan after subtracting Charges Not Covered and the Provider Discount from the Amount Billed.
25. Deductible Amount: the amount of allowed charges that apply to your plan deductible that must be paid before benefits are payable.
26. Copay: the amount of allowed charges, specified by your plan, that you must pay before benefits are paid.
27. Covered Amount: eligible charges considered under your plan.
28. Paid At: the percentage of the Covered Amount that will be considered under your benefit plan.
29. Payment Amount: benefits payable for services provided.
30. Column Totals: the sum of each column.
31. Patient Responsibility: after all benefits have been calculated, this is the amount of the enrollee’s responsibility for this claim.
32. Other Credits or Adjustments: represents adjustments based upon the benefits of other health plans or insurance carriers, including Medicare.
33. Total Payment: the sum of the “Payment Amount” column.
34. Remark Code Description: additional explanation of the Remark or Discount Code will appear in this section.
35. Paid To: individual or organization to whom benefits are paid.
36. Check Number: the unique number assigned to the check.
37. Check Amount: total benefit amount paid on this claim.
38. Plan Status: deductible/out of pocket status for the current year.
39. Foreign Language Assistance: multilingual contact information will only appear when applicable.
40. Going Green: HealthSmart offers members the option to receive electronic, paperless Explanation of Benefit (EOB) notifications.
41. Important Information: statement explaining your entitlement to a review of the benefit determination on the Explanation of Benefits (EOB). This information varies
according to each plan.
Some related terms
EXPLANATION OF BENEFITS:
The time frame that payor gives to the provider to submit the claims and get reimbursed. Timely filing limit starts from date of service in case of outpatient claims and from date of discharge in case of inpatient claims.
TIMELY FILING LIMIT: The time frame that payor gives to the provider to submit the claims and get reimbursed. Timely filing limit starts from date of service in case of outpatient claims and from date of discharge in case of inpatient claims.
APPEALS TIMELY FILING LIMIT: The time frame that the insurance company gives to the provider to submit the claims and get reimbursed after the claim has been denied. Appeals limit starts from the date of denial