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How to Read Your Explanation of Benefits

Many people find their Explanation of Benefits statements difficult to understand or confuse them with a bill.

Different insurers use different terms and formats, so you should direct specific questions to your insurance company. But here’s a general guide for how to make sense of your EOB.

What to Check For

  • First of all, you’ll notice the name of the doctor or facility that billed your insurance company. The location may be unfamiliar if you had lab work or an X-ray, which is often read in a different location.
  • Look for the date of your procedure or service visit. This could differ from the date of your visit for the same reason as above.
  • Next, look for the procedure code. Insurers often use this in place of a written explanation of what procedure you had done to protect your privacy in case your EOB falls into the wrong hands.

Understanding the Numbers

  • “Member’s Deductible” or “DED.” This figure, if one is listed, is the amount that was applied to the deductible on your policy.
  • “Copay Amount.” This is the amount, if any, that you were supposed to pay in the office at the time of service.
  • “Co-Ins” stands for co-insurance. This is the amount if any, that is your responsibility after your insurer pays its portion.
  • “Adjustments.” Here you will see any adjustments to what the provider billed and what the insurance plan allows. You should only have to pay the amount that the insurance allows. If a doctor’s office charges you for the unadjusted amount, contact your insurance company to determine whether the office is a contracted provider – meaning it agrees to accept an insurer’s negotiated payment amount as payment in full. If not, you may be responsible for the difference.
  • “Insurance Paid” or “Amount Paid.” This states how much of the bill was paid by your insurer.
  • “Patient Responsibility,” “Your Balance” or “Your Responsibility.” This is the remaining balance after your insurance plan has paid its portion of the bill, minus any adjustments, including any copay, co-insurance and deductible amounts. This amount should match the amount that your provider bills you.

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