An Explanation of Your Explanation of Benefits (EOB)

An Explanation of Your Explanation of Benefits (EOB)

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 a health insurance Explanation of Benefits (EOB)?

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

Your EOB statement is an important record of claims for medical services and benefit coverage. The first thing you should do is 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.)

The EOB has three 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. For the first time, this new EOB breaks out the savings that your BCBS benefits plan provides for you - negotiated provider discounts and other deductions – from any amounts that may not covered.
  • Summary shows you a clear picture of your deductible, coinsurance, copays, and health spending accounts, if applicable.

The EOB may include additional information:

  • Amounts Not Covered will show provider discounts, or what benefit limitations or exclusions apply.
  • Out-of-Pocket Expenses will show an amount when a claim applies toward your deductible or counts toward your out-of-pocket expenses.
  • Appeals explains your rights regarding review of claim denials.
  • Fraud Hotline is a toll-free number to call if you think you are being charged for services you did not receive or if you suspect any fraudulent activity.

Check out the sample EOB below. 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.

Key areas of your EOB:

  1. Member’s name and mailing address
  2. Member ID and group number
  3. Summary box for all claims including total billed by the provider, and discounts, reductions or payments made, and the amount you may owe
  4. Detailed claim information for each claim
  5. Patient name and service date
  6. Provider information
  7. Claim number and date the claim was processed
  8. Service description
  9. Amount billed for each service
  10. The amount covered (allowed) for each service and the discounts or deductions subtracted from the amount your provider billed
  11. Your share of the costs
  12. Claim summary with amount covered less your responsibility
  13. Deductible and/or out-of-pocket expense information
  14. Health Care Fraud Hotline

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!

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