Make Sense of Your Insurance Statement

Every time you go to the doctor, get a test or get any other kind of medical service, your health insurance company should send you an Explanation of Benefits or EOB.

This document details what service you received, what provider you saw, how much the insurance company paid, and how much you owe. If a service was denied, the EOB will tell you why. It is important that you review the EOB when you get one to make sure it is correct and that you are not expected to pay more than you should.

If payment for a service has been denied, the back of the EOB should tell you how to file an appeal and where.

Learn about to appeal health insurance denials at The Rule Book: How to Fight Back.

See the sample EOB below. Click on the circled items for an explanation of what that item is. Keep in mind that each insurance company has its own EOB form, so yours may not look exactly like this one. However, the elements should be similar.

Sample EOB
  1. Service Date. This is the date you received the services. If you did not receive any services that day or from the provider listed, let the insurance company know. It could be a fraudulent claim.

  2. CPT Code. Known as “Current Procedure Terminology” codes, these 5-digit numbers signify exactly what procedure was performed.

  3. Description. Describes the procedure in English, instead of code. If you do not think you received the procedure listed, contact the provider listed to ask what it is.

  4. Quantity. How many of that service your received.

  5. Billed Amount. This is how much the doctor, hospital or other health care provider billed your insurance company for the procedure. This is amount is pretty meaningless because you can only be charged the amount your providers agreed to accept when they signed on to be part of your insurance company’s network of providers. The billed amount is usually inflated because providers need to be able to give the insurance companies a “discount.” Unfortunately, this is the amount people who do not have insurance are billed.

  6. Max Amount. This is the maximum amount the insurance company will pay for this particular service in your area. This is usually much lower than the billed amount.

  7. Deductible Amount. A deductible is the amount of money you must pay before the insurance company pays anything. If your health insurance has a deductible, the amount in this column is how much of the Max Amount will go towards your deductible. You have to pay the amount in this column to the health care provider that performed the services. The insurance company should keep track of how much you have already been billed toward your deductible.

  8. Copay/Co-insurance Amount. This is the amount you have to pay to health care provider that performed the services. If you already paid a copay or coinsurance at the time you received the services, make sure the amount listed here is what you paid. If you paid less, you owe the provider. If you paid more, contact your provider to get a refund. In this EOB you do not owe any copay/co-insurance. Whether you pay one and how much it is depends on your insurance benefits package.

  9. Adj Code. If a correction, adjustment or denial has been made on the claim, a code signifying the reason for it will be listed here. If a service has been denied, a definition of the code listed here would then appear on the EOB below the Claim Payment Summary. The adjustment codes in this EOB are NY state mandated adjustments to help hospitals pay for care for the uninsured.

  10. COB Amount. This refers to “Coordination of Benefits.” If you have other health insurance that pays first (is primary), this column will shows the amount paid by your other insurance.

  11. Payment Amount. This is the total amount your insurance company will pay your health care provider for the service performed. Adding this amount to the copay/coinsurance amount, the deductible amount and any COB amount, should equal the Max Amount. In this example, the insurance company will pay the hospital $2,790.74 for the procedure. You have to pay $539.26, after which you have met your annual deductible. That adds up to the Max amount of $3,330 (mush less than the billed amount of $11,237.16).

  12. Claim Payment Summary. This is the total for all the services billed to your insurance on this EOB. With the adjustments, your insurance company is paying the hospital $2,835.04.

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