What an EOB is
When you get care, the provider sends a claim, a request for payment, to your plan. The plan decides what it covers and sends you an explanation of benefits. CMS describes it as a list of the total charges for a visit with what the plan covers; it is not a bill, and it shows what you may owe once the provider bills you. Each EOB covers a claim, so a visit that involved more than one provider can mean more than one EOB, each to be matched with its own bill.
Line by line
Layouts differ between insurers, but the fields are the same. The names in the first column are the ones CMS uses; your plan may say "amount billed" or "plan discount" instead.
| Field | What it means | In the example below |
|---|---|---|
| Patient and plan | Who got care, under which plan | You, your plan |
| Provider, date of service | Who treated you and when | Check it matches your visit |
| Claim number | The plan's reference for this claim | Quote it when you call |
| Provider Charges | What the provider billed | $1,200 |
| Allowed Charges | What the provider will be paid in total, the plan's allowed amount | $800 |
| Paid by Insurer | What the plan pays the provider | $400 |
| What You Owe, Patient Balance | Your share after the plan has paid | $400 |
| Remark codes | Short notes from the plan on the charges, costs or payments; the key is at the bottom | Why part of the claim went to the deductible |
| Payee | Who gets reimbursed for any overpayment | Check the name |
The allowed amount is the line that explains most of the gap. HealthCare.gov defines it as the most a plan will pay for a covered service, also called the negotiated rate. A provider in your plan's network has agreed to it, and a preferred provider may not bill you for the difference between its charge and the allowed amount for covered services.
A claim worked through
A provider in your network bills $1,200. The plan's allowed amount is $800. You still have $300 of your deductible to meet this year, and after that you pay 20 percent coinsurance. HealthCare.gov's order is deductible first, then coinsurance on what is left.
- Discount. $1,200 − $800 = $400. In network, this disappears; it is not your share.
- Deductible. The first $300 of the allowed amount is yours. Your deductible is now met.
- Coinsurance. 20% of the remaining $500 is $100.
- You owe. $300 + $100 = $400, the patient balance.
- Plan pays. $800 − $400 = $400.
The check: plan paid plus you owe equals the allowed amount, $400 + $400 = $800. If the provider's bill later asks for $800, it is charging you the discount as well, and that is the kind of mismatch to question. The percentage calculator does the coinsurance step for any amount, and the budget planner holds the payment if you set one up. The guide deductible vs out-of-pocket maximum shows how claims like this add up over a year.
Comparing the bill with the EOB
CMS says the EOB normally arrives before the provider's bill. The bill uses its own words for the same amounts: total charges, allowed amount, adjustments for the provider's reductions, insurance payment, patient payment for anything you already paid such as a copay, and balance due. Lay the two side by side and check:
- The same provider, the same dates of service, the same services.
- The balance due on the bill is not higher than the patient balance on the EOB. CMS says it should not be.
- Any copay you paid on the day appears as a patient payment. The EOB itself does not show what you already paid.
When the bill and the EOB disagree
- Do not pay the higher amount yet. CMS advises paying only after you receive a bill and confirm it matches the EOB.
- Call the provider's billing office. Give the account number from the bill and the claim number from the EOB. Ask for a corrected bill, or a refund if you already paid.
- Call the plan if there is no EOB. A bill without an EOB can mean the claim was never filed. CMS says to ask the plan to confirm a claim was submitted.
- Appeal a denial. If a remark code shows the plan denied the service, you can ask the plan to review the decision. The steps and deadline are in the denial notice and your plan documents.
- Get help with surprise bills. For emergency care, or out-of-network care at an in-network facility, the No Surprises Help Desk at 1-800-985-3059 takes questions and complaints.
Keep every EOB until the matching bill is settled. Notes of each call, with the date and the name of the person, make a later complaint or appeal much easier.
If the bill is for emergency care or comes from an out-of-network provider at an in-network facility, check it against the rules in the No Surprises Act guide before you pay.
Checking for care you never got
An EOB is also an early warning. The FTC lists a bill or an EOB for services you did not get as a sign of medical identity theft, along with debt collection calls about medical debt you do not owe. If you see one, ask each provider and the plan for your records, report errors to the provider in writing, check your credit reports, and make a recovery plan at IdentityTheft.gov.
Medicare's version
People with Original Medicare get a Medicare Summary Notice instead, every six months if they had services or supplies in that period. It is not a bill either. It lists what providers billed to Medicare, what Medicare paid and the most you may owe, and Medicare.gov suggests comparing it with your receipts and bills. If you disagree with a decision, the last page explains how to appeal.
Frequently asked questions
Is an explanation of benefits a bill?
No. CMS describes the EOB as a statement from your health plan that lists the total charges for a visit and shows how much the plan covers. It shows what you may owe once your provider bills you. Treat it as a preview of the bill and a record to check the bill against.
Should I pay the amount on the EOB?
Not to the plan, and not before you have a bill. CMS advises keeping all EOBs and paying only after you receive a bill from the provider and confirm it matches the EOB. The EOB also does not show whether you already paid part of the amount, such as a copay at the front desk.
Why is the allowed amount lower than what the provider billed?
The allowed amount is the most the plan will pay for a covered service, sometimes called the negotiated rate. A network provider has agreed to that price with the plan, and HealthCare.gov notes that a preferred provider may not balance bill you for covered services. The difference is a discount, not something you owe.
What if the bill is higher than the EOB says I owe?
CMS says your bill should not be higher than the patient balance on the EOB. Contact the provider's billing office, point to the EOB, and ask for a corrected bill or a refund if you already paid. If you received a surprise bill for emergency care or out-of-network care at an in-network facility, the No Surprises Help Desk is at 1-800-985-3059.
What if I get an EOB for care I never received?
The FTC lists that as a warning sign of medical identity theft. Call your plan and the provider, ask for your medical records, report errors in writing, and use IdentityTheft.gov to make a recovery plan. Also check your credit reports for medical debts you do not recognize.
Sources
- CMS: How to read a health insurance explanation of benefits (an EOB is not a bill; patient, plan, claim number, payee and phone number; Provider Charges, Allowed Charges, Paid by Insurer, What You Owe or Patient Balance; remark codes explained at the bottom; the bill should not be higher than the patient balance)
- CMS: How to read your medical bill (total charges, allowed amount, adjustments, insurance payment, patient payment, balance due; the EOB usually arrives before the bill; keep EOBs and pay only after the bill matches; contact the plan if no EOB arrived)
- CMS: Action plan for a surprise bill after an emergency room visit (compare the What you owe column with the bill; ask the provider to reduce the bill or refund; complaint and No Surprises Help Desk at 1-800-985-3059)
- CMS: Dispute a medical bill (with insurance, appeal a denied claim using the process in your plan documents and denial notices; Help Desk complaints for surprise bills)
- HealthCare.gov glossary: Allowed amount (the maximum a plan will pay for a covered service; also called eligible expense, payment allowance or negotiated rate)
- HealthCare.gov glossary: Balance billing (the difference between the provider's charge and the allowed amount; a preferred provider may not balance bill for covered services)
- HealthCare.gov glossary: Claim (a request for payment that you or your provider submits to your health insurer)
- HealthCare.gov glossary: Appeal (a request to your insurer to review a decision that denies a benefit or payment)
- HealthCare.gov: Your total costs for health care (the deductible first, then coinsurance; Jane's example of 20 percent of a $125 visit)
- Medicare.gov: Medicare Summary Notice (sent to people with Original Medicare every six months if they had services; not a bill; compare it with receipts and bills; appeal steps on the last page)
- FTC: What to know about medical identity theft (an EOB for services you did not get as a warning sign; get records, report errors in writing, a 30-day response, credit reports, IdentityTheft.gov)
General information based on the sources above, not tax, legal or financial advice.