Health insurance coverage can be very tricky. Having a great understanding of what is and what is not covered by your health insurance can save you a lot of time and money. In this presentation, we take you through everything you need to know about your Explanation of Benefits Statement. Become familiar with the vocabulary and areas you should pay specific attention to so you aren't being overcharged for care.

1. Everything you need to know about
your Explanation Of Benefits

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•An EOB is a statement sent by a
health insurance company to covered
individuals explaining what medical
treatments and/or services were paid
for on their behalf.
**AN EOB IS NOT A BILL**
WHAT IS AN EOB?

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WHY IS AN EOB IMPORTANT?
✕ 1. An EOB verifies that a claim was received and documents payment
and/or reason(s) for denial and patient responsibility.
✕ 2. An EOB provides the correct “contract allowance” that an in-network
provider has agreed to accept as plan payment and clearly specifies your
patient responsibility.
✕ 3. Secondary (i.e., spouse) insurance requires a primary EOB before
releasing payment to your provider.

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WHAT IS ON AN EOB?
✕ 1. Claim Information.
✕ 2. Member Name.
✕ 3. Identification Number.
✕ 4. Group Number.
✕ 5. Summary of Total billed charges.
✕ 6.Service Information (service Description- XRAY, Office Visit).
✕ 7. Date(s) of Service.
✕ 8. Amount billed for individual services.
✕ 9. Coverage Information/Deductions.
+ Coinsurance Amount/ Total benefits approved.
✕ 10. Amount You MAY Owe Provider.

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DEFINITIONS
✕ Claim- A request for compensation under the terms of an insurance
policy.
✕ Co-Insurance- A type of insurance in which the insured pays a share of
the payment made against a claim.
✕ Remark Code: It communicates why a claim or service line was paid
differently than it was billed.
✕ In Network Benefits VS Out of network: In Network- Providers have
agreed to accept a plan’s contracted rate as a payment in full services.
Out of Network – Providers have not agreed to any set rate with insurer,
and may charge more. Which may include but not limited to Higher Co-
Pays, Higher Co-Insurance, and Higher Deductible.
✕ Current Procedural Terminology Code(CPT)- medical code that is used
to bill medical, surgical and diagnostic procedures to physicians, health
insurance companies, and accreditation organizations.
In the Next Two slides is a Sample EOB from
an insurance company that lists information
creating an EOB.

6. BREAKING DOWN AN EOB.
•Making sure the provider billing the
insurance has the proper Demographic
and Insurance information is very
important in determining whether or not
the insurance company will pay the
claims submitted.
Incorrect clerical mistakes may
cause you to receive another
person’s EOB or vies versa.

7. Summary: total billed by the provider for
the services. The summary will also show
the benefits approved and paid by the
health insurer.
Service information will include Date of
Service, Type of services rendered/billed,
covered/non covered charges.
Coverage Information: Type of plan(PPO,POS,HMO,EPO),
Deductions, Co-Ins, If claim was approved or denied, amount
approved, and an estimate of what provider is owed.
The splitting of insurance and patient responsibility.
(90/10)

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WHAT IS A CLAIM DENIAL?
✕ The Healthcare industry does not have a universal definition of a claim
denial: “Any intentional reduction of payment resulting from the failure
to provide medically necessary services in an appropriate setting, failure
to follow the payers’ technical guidelines, or failure to consistently
document for the services provided.” (HFMA) –
✕ Why are Denials Difficult?
+ Complex situations of third party billing and denials
+ Constantly changing information
+ Challenging appeals process
+ Denial information is not standardized through out the health
care system.

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TOP ERRORS ON AN EOB
✕ Double billing: Being charged twice for the same services, drugs, or supplies.
✕ Typos: Incorrect billing codes or dollar amounts.
✕ Canceled work: Charging for a test your doctor ordered, then canceled.
✕ Phantom services: Being charged for services, test or treatments that were
never received.
✕ Up-coding: Inflated charges for medications and supplies.
+ If you had to go to the hospital for treatment or had surgery, also watch for
these errors:
✕ Incorrect length of stay: Most hospitals will charge for the admission day,
but not for day of discharge. Be sure you’re not paying for both.
✕ Incorrect room charges: Being charged for a private room, even if you
stayed in a semi-private room.
✕ Inflated operating room fees: Being billed for more time than was actually
used.

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COMMON REASONS FOR CLAIM DENIALS
✕ Out of network provider.
✕ Termination of coverage.
✕ Failure to obtain correct authorization.
✕ Non covered service.
✕ Untimely filing.
✕ Services not medically necessary.
✕ Additional information needed(Progress notes, Test
results).
The next slide shows an EOB with denial reasons.

11. Remittance Advice Remark Codes (RARCs) are used to provide
additional explanation for an adjustment already described by a
Claim Adjustment Reason Code (CARC) or to convey information
about remittance processing.

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REFERENCES
www.bcbs/eobexplanation.com
http://www.kern.courts.ca.gov/
http://www.insuranceclaimdenialappeal.com/
https://www.premera.com
Denial Management And how to Interpret an EOB
Webinar Presented by Jesse Snyder.

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We hope you now have a better
understanding of your EOB
Visit us at Disputebills.com to learn how we can
help you save money. Our mission is to save you
20% to 30% per year on healthcare expenses.