How to Read an Explanation of Benefits (EOB)

How to Read an Explanation of Benefits (EOB)
(text version) 01/01/2012
In the upper left corner of the first page of your Explanation of Benefits (EOB), you will find
the name and return address of the Coventry health plan that processed your claim(s). Below the
name and address you will see the words "Electronic Service Requested;" this is a mailing instruction
to the United States Post Office. Below these words, you will find your name and address.
To the right or below your name and address, depending if there is a check attached to your
EOB, is a reference box with a title of "Payments made on behalf of:" at the top of the box. In this
box, you will see the name of the carrier. The carrier is the company that pays your medical claim.
Just below the carrier name is your name as the patient and insured, the individual who received
medical services. After the patient name is your group name and patient identifier. The patient
identifier is the unique number assigned to you for the doctor and insurance company to easily identify
you in their computer systems. The last item in this box is the date your claims were processed.
If a payment is being made to you, a check will be attached below the reference box and your
claim detail information will begin on page 2 of your EOB. If there is no payment or the payment
was made directly to your medical provider, no check will be attached and the claim detail will be
directly under the reference box.
There may be times that your insurance carrier needs to provide important information on your
explanation of benefits. If there is a message, a message box will be placed on your EOB just before
your claim detail information begins. The message box will begin with the words "Important Benefit
Information" and then the message directly below.
Below the header information, the claim detail section of your EOB begins where the phrase
"**Payments made at the time services were rendered are not reflected on this statement**"is printed
in bold letters. This statement serves to remind you that if you paid any money to your doctor, it will
not be shown on this EOB. Following this statement you will see a claim header box. Each claim's
detail will begin with a header box. If you have multiple claims on your EOB, each claim will have a
new header box. The header box includes the following information:
1. Claim Number: the number assigned by your insurance company to identify each unique
claim.
2. Paid to Provider, Paid to Member & Paid to Other: the dollar amount paid to each of these
entities.
3. Total Plan Paid: total benefit paid.
4. Check Number: if the payment was made to you, the check number will be displayed.
5. Provider: the name of the health care provider that you provided care to you. This may be a
physician name or a facility name.
6. Provider Billing Address: the address of your health care provider. The address is for the
provider’s billing office, and it may or may not be the same address where you received
treatment.
7. Patient Account #: the patient’s identification number assigned by your health care provider.
8. The claim detail table following the claim header box contains additional information about the
claim that was processed by your health insurer. The description of each item is above the
actual information and should be read as a column. There is a thin line separating the
description from the actual information: Service Date From - To and Proc Code /
Description: the Service Date is the date of your visit to your health care provider and is found
directly under the description in bold letters. Below the date is a standard health care industry
code and a short description of the services performed. This may be an office visit, surgery, or
a test that was performed.
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9. Billed Amount: the dollar amount the provider billed the insurance company for the service
they provided.
10. Contractual Adjustment: Reductions in payment due to contracts with your health care
provider, coordination of benefits or non-covered services that may/may not be your
responsibility.
11. Approved Amount: the amount Coventry agrees to pay the provider for services rendered.
12. The next four columns show the breakdown of the dollars that you as the member are
responsible to pay to your health care provider:
Copay: the amount of the copay for the service provided. Copay amounts are defined
in your member handbook. This item will be shown in the totals row at the end of this
claim's detail.
Coins: the coinsurance amount is the members shared expenses for charges based on a
percentage and is determined by the members benefit plan. This item will be shown in
the totals row at the end of this claim's detail.
Deduct: the deductable amount is the dollar amount for this claim that the member
must pay before the insurance company starts to pay for claims. This is also
determined by the members benefit plan. This item will be shown in the totals row at
the end of this claim's detail.
Other: the dollar amount the member is responsible for that does not fall into the
Copay, Coinsurance or Deductible categories. Description of the dollars that fall into
this category will be shown in the Other Rmk area described below. This item will be
shown in the totals row at the end of this claim's detail.
Plan Paid: the amount your insurance company paid for this one service. This item
will be shown in the totals row at the end of this claim's detail.
Cont./ Rmk and Other Rmk: these are numeric codes used to communicate the
reasons for determination of payment. The description of the numeric code(s) is
located at the end of your EOB directly after the last Claim detail, under the title(s)
"Contractual Remarks" or "Other Remarks".
Below the claim's detail is a TOTALS: line. The total line is adding up each dollar amount
column of the individual service into one claims total. This is the total for one claim only; it
will not total multiple claims on the EOB.
If applicable to your plan, below the TOTALS: line is a Coordination of Benefits: line for
each claim and displays two fields:
Other Carrier Allowed: the dollar amount your other health care insurance plan
considered for payment.
Other Carrier Paid: the dollar amount paid by your other health care insurance plan.
After the last claim on the EOB there will be a Complaint and Appeals Procedures section.
This section will detail how to get additional information about your claims.
Some EOBs will include a Benefit Usage Grid. This will be found at the bottom of your EOB.
This is only displayed if your medical benefit plan has a deductible and/or out of pocket limits. The
Benefit Usage Grid will show the Deductible and Out of Pocket amounts for your benefit plan and
what amounts have already been satisfied.
The last page or back of the last page of your EOB will show your Appeal Rights. This
information will give you the name, address and/or phone number you can contact if you disagree with
any of the information provided on your EOB.
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