An EOB is not a bill. It is the plan’s explanation of how a claim was paid.
EOB stands for explanation of benefits. After your health plan processes a claim, it sends a statement showing what the provider charged, what the plan covered and what you may owe. Here is what is on it and where to find yours.
Explanation of benefits, in plain terms.
The plan sends one for each claim it processes. It tells you what happened to the claim, so you can check it before you pay the provider.
It Is a Statement, Not an Invoice
The EOB says “this is not a bill” for a reason. The provider sends the bill. The EOB shows how the plan treated the claim. Keep it with your records, but do not send payment based on it. Wait for the provider’s bill and compare the two.
It Shows the Plan’s Decision
Covered, partly covered or denied, with a reason code or short explanation if the plan did not pay in full. If a claim was denied, the explanation is the starting point for any question to the plan or an appeal, so read it before calling.
It Shows Your Share
What was applied to your deductible, your copay or coinsurance, and the amount you may owe the provider. These figures show how much of your deductible you have used, so they are worth tracking through the year. Compare them with the provider’s bill before you pay.
The lines that matter most.
Billed and Allowed Amounts
Billed is what the provider charged. Allowed is the rate the plan recognizes for that service. The difference is not always yours to pay. If a bill uses the billed amount instead of the allowed amount for an in-network provider, ask the billing office to explain why.
What the Plan Paid
The portion of the allowed amount the plan covered after your deductible, copay and coinsurance. It is not the same as what the provider charged, so do not expect the plan’s payment to equal the billed amount. Read this line next to the allowed amount.
Your Responsibility
The amount you may owe the provider. Compare it to the provider’s bill before paying. If the provider’s bill is higher than this figure for an in-network service, ask the billing office to explain before you pay. Keep the EOB until the claim is settled.
Date, Provider and Claim Number
Check that the service, the patient and the date are right. You will need the claim number if you call the plan. A wrong date or name can be a processing mistake, so report it to the plan quickly. Keep a note of who you spoke with.
Denial or Adjustment Notes
If a service was denied, the reason is listed here. See denied claims and appeals.
Appeal Information
The EOB usually says how and by when you can appeal a decision. Deadlines are short, so act soon if you disagree. Keep copies of the EOB, the bill and any notes from calls, and ask the plan for its appeal process in writing.
Four places an EOB usually lives.
The Member Portal or App
Most plans post EOBs in the member account, often under claims or documents. This is the fastest place to look. Log in after a visit to see whether a new statement has been posted. Choosing paperless delivery can keep your records in one place.
Your Mail or Email
Some plans mail EOBs or send an email when a new one is ready, depending on your delivery settings. Check your notification settings so you do not miss one, and keep your contact information current with the plan. If a message looks unfamiliar, log in to your member account directly instead of clicking a link.
Ask the Plan
Member services can resend one, and can tell you which claim a statement relates to. Have the claim number and date of service ready when you call, and note the date and name of the person you speak with. Ask for a reference number.
Separate for Dental, Vision and Drugs
Dental and vision plans, and sometimes the pharmacy benefit, send their own statements. Check each benefit’s member site or mailbox separately, since a missing statement may simply be coming from another plan or carrier. Keep them together for a full picture of what you paid.
An EOB can also help with other paperwork. See the reimbursement request form and coordination of benefits, where another plan may ask for yours.
One claim, line by line.
An illustration only, with round numbers. Your plan’s deductible, coinsurance and rates will differ. Assume an in-network visit, a $200 deductible still unmet and 20% coinsurance.
The Provider Billed $1,000
This is the provider’s full charge. It is the starting point, not the amount anyone owes.
The Plan Allowed $600
The plan’s contracted rate for the service. For an in-network provider, the $400 difference is a contractual write-off, not your bill.
$200 Went to Your Deductible
You pay the first $200 of the allowed amount yourself, because the deductible had not been met.
Coinsurance Was $80
20% of the remaining $400 of the allowed amount. This is your share after the deductible.
The Plan Paid $320
The allowed amount, less the deductible and your coinsurance.
You Owe $280
The $200 deductible plus the $80 coinsurance. The provider’s bill should match this number.
Terms you will see on an EOB.
Allowed Amount
The most the plan recognizes for a service. Also called the eligible expense or negotiated rate. Charges above this amount for an in-network service are generally not your responsibility. Your EOB and plan documents show how your plan applies it. Ask the plan if the term on your statement is unfamiliar.
Adjustment or Discount
The part of the bill the provider writes off under its network contract. Look for it as a separate line. It is not money you owe, so do not pay it. If you see it added back into a balance, ask the provider’s billing office why.
Deductible, Copay and Coinsurance
Deductible is what you pay before the plan pays. A copay is a flat fee for a service. Coinsurance is your percentage share. Your plan documents list the amounts, and an EOB shows which one applied to each claim. If the terms are new to you, ask the plan to walk through an example.
Out-Of-Pocket Maximum
The most you pay in a plan year for covered, in-network care. The EOB often shows how much you have used so far. Out-of-network care and some costs may not count toward it, so check your plan documents before assuming a bill is capped.
Network Status
Whether the provider was in or out of the plan’s network. Out-of-network claims often pay less. Checking this before a visit helps you avoid surprises. Look up the provider in the plan’s directory or call the plan before scheduling, since network lists change.
Remark or Reason Codes
Short codes or notes explaining why a claim was paid, reduced or denied. The EOB or the plan will translate them. Call the plan if a code is unclear, and ask for the explanation in writing. Keep a note of what you were told.
Six things worth checking on every EOB.
Is it your service?
Confirm the patient, provider and date of service. A wrong date or a service you did not receive is worth a call.
Is it a duplicate?
The same claim can be billed twice. Two EOBs for the same visit usually mean one should not be there.
Does the bill match?
The provider’s bill should match the patient responsibility on the EOB. A higher bill from an in-network provider deserves a question.
Was the right network used?
If the provider should have been in network but the claim was processed as out-of-network, ask the plan to review it.
Was anything denied?
A denial may be a coding or paperwork error that the provider can fix. See denied claims and appeals.
Did another plan pay first?
If you have more than one plan, the order matters. See coordination of benefits.
Many different statements look like an EOB. Dental, vision and the pharmacy benefit can each send their own, and Medicare sends a Medicare Summary Notice instead. If you cannot tell which one you are holding, the plan name at the top is the place to start. For the accounts we serve, our claims advocacy team can help sort out a claim that does not look right.
Two separate documents, and the second should match the first.
The Insurer Sends the EOB
Once the plan processes the claim, it sends the EOB. The provider sends its own bill afterward if a balance remains. Wait for it before paying anything. If you receive a bill first, treat it as a heads-up and not a final amount until the EOB arrives.
Timing Varies
The EOB often arrives around the same time as the bill, or shortly before it. Do not pay a bill until you have seen the EOB for that claim. Keep every EOB and bill together so you can match them when they do arrive.
Compare the Two
For an in-network provider the bill should match the patient responsibility on the EOB. It should not be higher. Match the amounts line by line, including the date of service. If they do not agree, move to the next step before you pay.
If the Bill Is Higher
Call the provider’s billing office first and ask them to explain the difference. If it is not resolved, call the plan with the claim number. Keep notes of who you spoke with and when, and ask for any correction in writing. Ask whether the account can be placed on hold while it is reviewed.
Keep the Deductible Tracker in View
Many EOBs show how much you have met toward your deductible and out-of-pocket maximum this year. That is useful for planning the next claim. Reviewing it before elective care helps you estimate what you may owe. Your plan portal may show the same balances in real time.
Out-Of-Network and Non-Covered Services
These can legitimately leave you owing more, because the provider is not bound by the plan’s rates. The EOB will show it as not covered or reduced. Check network status and coverage before scheduling care, and ask the plan for an estimate when you can.
What people ask about EOBs.
Do I have to pay what the EOB shows?
The EOB shows what you may owe. Wait for the provider’s bill, and compare the two before you pay.
Why did I get an EOB but no bill?
Bills often arrive later. The EOB shows the claim was processed.
Does an EOB mean the claim was approved?
Not always. It shows the decision, which could be covered, partly covered or denied.
What if the EOB looks wrong?
Call the plan with the claim number. If it is a coverage decision you disagree with, appeal. See denied claims and appeals.
Does my employer see my EOBs?
The plan sends them to the policyholder, not to the employer. Employers do not need claim detail.
How long should I keep them?
Keep them at least until the claim and any bills are settled, and longer for large or disputed claims.
Related reading: Denied claims and appeals · Claims advocacy · Reading your plan documents · Subrogation form · Referrals and prior authorizations
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