Health insurance 101 – How to read your Explanation of Benefits ( EOB)

[Seventh in a series of posts to help you better understand health insurance and how recent changes affect you.]

Many people find their Explanation of Benefits statements difficult to understand or confuse them with a bill.

Different insurers use different terms and formats, so you should direct specific questions to your insurance company. But here’s a general guide for how to make sense of your EOB:

First of all, you’ll notice the name of the doctor or facility that billed your insurance company. The location may be unfamiliar if you had lab work or an X-ray, which is often read in a different location.

1. Look for the date of your procedure or service visit. This could differ from the date of your visit for the same reason as above.
2. Next, look for the procedure code. Insurers often use this in place of a written explanation of what procedure you had done to protect your privacy in case your EOB falls into the wrong hands.
3. “Member’s Deductible” or “DED.” This figure, if one is listed, is the amount that was applied to the deductible on your policy.
4. “Copay Amount.” This is the amount, if any, that you were supposed to pay in the office at the time of service.
5. “Co-Ins” stands for co-insurance. This is the amount, if any, that is your responsibility after your insurer pays its portion.
6. “Adjustments.” Here you will see any adjustments to what the provider billed and what the insurance plan allows. You should only have to pay the amount that the insurance allows. If a doctor’s office charges you for the unadjusted amount, contact your insurance company to determine whether the office is a contracted provider – meaning it agrees to accept an insurer’s negotiated payment amount as payment in full. If not, you may be responsible for the difference.
7. “Insurance Paid” or “Amount Paid.” This states how much of the bill was paid by your insurer.
8. “Patient Responsibility,” “Your Balance” or “Your Responsibility.” This is the remaining balance after your insurance plan has paid its portion of the bill, minus any adjustments, including any copay, co-insurance and deductible amounts. This amount should match the amount that your provider bills you.

Next week: Provider charges vs. what insurers pay