An Explanation of Your Explanation of Benefits

An Explanation of Your Explanation of Benefits

You’ve been to the doctor and paid your copay. How are you going to know when your claim is filed and finalized? Simple, you’ll get your Explanation of Benefits (EOB). Your EOB will break down the service you received at the doctor’s office, the cost and what you might have to pay.

What Is an EOB?

An EOB is a notice you get when a health care benefits claim is processed by your health plan. The EOB shows the expenses submitted by the provider and how the claim was processed. In most cases, an EOB will be mailed to you after a claim has been finalized. If you are a Blue Cross and Blue Shield of Texas (BCBSTX) member and signed up for paperless statements, you'll get an email notice when your EOB is ready for viewing through your Blue Access for MembersSM (BAM) account .

The EOB Has 3 Main Sections
  • Total of Claim(s) highlights the major financial information about your claims – the amount billed, total benefits approved and the amount you may owe to the provider. Sometimes one EOB may contain more than one claim.
  • Service Detail for each claim identifies each service you or your dependent received, the facility or physician, dates of service and the charges – both billed and allowed. The EOB also breaks out the savings that your BCBS benefits plan provides for you - negotiated provider discounts and other deductions – from any amounts that may not be covered.
  • Summary shows you a clear picture of your deductible, coinsurance, copays, and health spending accounts, if applicable.

Below is a sample EOB that labels all the sections. Keep in mind, every plan is different and the charges on your EOB are according to your plan’s coverage and the services you received.

 EOB example

Key Areas of Your EOB
  1. Member ID and group number
  2. Summary box for all claims including total billed by the provider, and discounts, reductions or payments made, and the amount you may owe
  3. Detailed information for each claim
  4. Patient name and service date
  5. Provider information
  6. Claim number and date the claim was processed
  7. Service description
  8. Amount billed for each service
  9. The amount covered (allowed) for each service and the discounts or deductions subtracted from the amount your provider billed
  10. Your share of the costs
  11. Claim summary with amount covered less your responsibility
  12. Deductible and/or out-of-pocket expense information
  13. Health Care Fraud Hotline
  14. Appeals information that explains your right to have a review if a claim is denied.
Always Check Your EOBs

Your EOB is an important record of claims for medical services paid from your benefits. You need to carefully check your EOB. You want to be sure that the services you received match the services you were billed for. If something looks wrong, call us using the number on the back of your Member ID card or call your doctor to ask about it. Then, keep your EOBs for future reference — just in case questions come up later about your claim or your bill. (Bonus: if you’ve registered for BAM, we store your EOBs there for 18 months.)

We know it gets a little tricky, so if you have questions about this explanation of your Explanation of Benefits, sign in and let us know in the comments below.

If you want to learn more about EOBs, go to BAM or check out any of these great Health Care Coverage 1-on-1 videos.

Originally published November 18, 2014