How do I read an Explanation of Benefits (EOB)?

Answer: 

An Explanation of Benefits (EOB) is a statement that your insurance company sends that summarizes the costs of health care services you received. An EOB shows how much your health care provider is charging your insurance company and how much you may be responsible for paying. This is not a bill. If you owe money, you will receive a separate bill from your health care provider. Individual EOBs are likely to differ from the example provided.

Example EOB Statement

Depicted in EOB statement example above, are these points for reference:

1 - SERVICE DESCRIPTION is a description of the health care services you received, like a medical visit, lab tests, screenings, surgery or lab tests.

2 - PROVIDER CHARGES is the amount your provider bills for your visit.

3 - ALLOWED CHARGES is the amount that your provider will be reimbursed, negotiated between the carrier and the provider (this may not be the same as the Provider Charges).

4 - PAID BY INSURER is the amount your insurance plan will pay to your provider.

5 - PAYEE is the person who will receive any reimbursement for over-paying the claim.

6 - WHAT YOU OWE is the amount the patient or insurance plan member owes after your insurer has paid. You may have already paid part of this amount, and payments made directly to your provider may not be subtracted from this amount. Wait to receive a bill from your provider before paying for the services.

7 - REMARK CODE is a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit.

Questions, Appeals and Grievances

Contact your health insurance company if you have any questions about your EOB, or if you have a complaint or are dissatisfied with a denial of coverage under your health plan, as you may be able to appeal the decision or file a grievance. If you think you were charged for services that your coverage is supposed to pay for, keep the bill and call the phone number on the back of your insurance card to speak with customer support. Check for services that were not performed. Some services might have been performed by a provider that has an arrangement with the organization you received care from, such as pathology and laboratory tests. Visit www.nh.gov/insurance for resources on dealing with denials or other complaints.