What is an EOB (Explanation of Benefits)?

Your Insurance Statement Explained

An Explanation of Benefits (EOB) is a statement from your insurance company explaining how they processed a medical claim. It's one of the most important documents for understanding your healthcare costs.

Important: An EOB is NOT a Bill

This confuses many people. Your EOB:

• Shows how insurance processed a claim
• Explains what was covered and what wasn't
• Indicates what you may owe the provider
• Is NOT a request for payment

You should wait for an actual bill from your provider before paying anything.

Key Sections of an EOB

Header Information

• Member Name - The covered patient
• Member ID - Your insurance identification number
• Claim Number - Unique identifier for this claim
• Date of Service - When care was received
• Provider - Who provided the care

Services Section

For each service, you'll typically see:

• Description - What was done
• Billed Amount - What the provider charged
• Allowed Amount - What insurance considers payable
• Plan Paid - What insurance paid the provider
• Your Responsibility - What you may owe

Payment Breakdown

• Deductible Applied - Amount toward your deductible
• Copay - Fixed amount for the visit type
• Coinsurance - Your percentage share
• Not Covered - Services excluded from coverage

How to Read the Payment Breakdown

Example EOB Line:

Description	Billed	Allowed	Insurance Paid	You Owe
Office Visit (99213)	$200	$125	$100	$25

This tells you:

1. Provider charged $200
2. Insurance allowed $125 (negotiated rate)
3. Insurance paid $100 (80% of allowed)
4. You owe $25 (20% coinsurance on allowed)
5. The $75 difference ($200 - $125) is written off

Common EOB Codes and Messages

• Claim Approved - Service covered and processed
• Applied to Deductible - You pay, counts toward deductible
• Not a Covered Service - Insurance doesn't cover this
• Provider Not in Network - May result in higher costs
• Pre-authorization Required - Service needed prior approval

What to Do with Your EOB

1. Compare to Your Records - Verify you received these services
2. Check for Errors - Wrong dates, services, or amounts
3. Save It - Keep for your records and tax purposes
4. Wait for the Bill - Don't pay based on EOB alone
5. Appeal if Needed - If something was wrongly denied

EOB vs. Medical Bill

EOB	Medical Bill
From insurance	From provider
Shows how claim was processed	Requests payment
"You may owe"	"Amount due"
Don't pay from this	Pay from this

Always compare your EOB to your medical bill. If they don't match, investigate before paying.