Your insurance company should send you a form explaining what they paid on charges submitted by your physician. This form is referred to as the Explanation of Benefits, or “EOB” for short.
Your Explanation of Benefits will tell you if your charges were applied to your deductible or denied for some reason. They will also tell you how much was paid, how much was adjusted off due to the contractual agreement between your insurer and your provider, and how much is left for you to pay.
Most EOB’s show a breakdown of the charges under several headings which usually read from left to right. The most common headings are:
- Date of Service - the date of the appointment or procedure.
- Services - codes used by the medical provider to tell the insurance company what services were rendered to the patient.
- Amount Billed - the amount of charges submitted by the medical provider.
- Approved Amount - the amount the insurance company approved for payment. Insurance companies often have pre-determined dollar amounts that they consider “usual and customary” for each medical service code. This pre-determined amount is often different than what your medical provider charges for that service. Depending on the contract or agreement between your insurance company and medical provider, or lack thereof, the difference between the Approved Amount and the billed amount may be adjusted (reduced to $0) or transferred to Patient Responsibility (see below).
- Amount Paid - the amount the insurance company paid to the medical provider for the services rendered.
- Applied to Deductible - the amount of charges that the insurance company has applied to the deductible. Most insurance plans require the patient to pay for a certain portion of their medical charges each plan year before the insurance coverage begins to pay. This is called the plan deductible and it comprises a portion of the total Patient Responsibility (see below).
- Applied to Co-insurance – the amount of charges that the insurance company has applied to the co-insurance element of the plan. Some insurance plans require the patient to pay for a percentage of the charges for each medical service. This is called co-insurance and it comprises a portion of the total Patient Responsibility (see below).
- Patient Responsibility - the amount you owe. This is made up of the deductible, co-insurance and any charges not covered by the insurance plan.
Sometimes the insurance company will deny (refuse to pay) a charge for some reason. In this case, the EOB will contain alpha or numeric codes next to each procedure which indicate the reason for the denial. The explanation of these codes will often be found at the bottom of the page or on the reverse of the EOB. Some denial codes require the patient to contact the insurance carrier in order to resolve questions or other issues that are preventing payment from being made.
It is advisable to compare insurance EOB’s to the bill received from the medical provider. Check to see if the payment was posted correctly and the amount owed on the bill matches the amount indicated on the EOB. Springfield Clinic makes this comparison easier by including detailed charge and payment information on all Clinic statements. Any questions can be directed to our Patient Service Representatives at 217.528.7541 or toll-free at 800.844.7541, Monday through Friday, 8:00 a.m. – 5:00 p.m.