What is Explanation of Benefits of Health Insurance in Medical Billing

Explanation of Benefits or EOB in Medical Billing and information available on the EOB of Health Insurances Company?

Explanation of Benefits describes the decisions that are taken during the adjudication by the insurance company are communicated to the provider and patient using a document called Explanation of Benefits or EOB. It is the detailed statement of the insurance determination of the claims processed and this determination can result in a payment or a denial, which we call by name payment EOB or denied EOB respectively.

The Explanation of Benefits contains the following information:

  • Payer Name – Payer Name is the name of the Insurance Company.
  • Payer Address – Payer Address is the address of the Insurance Company.
  • Patient Name – Patient Name is the name of the Patient
  • Provider Name and address – Name of the rendering provider and the address where the service provided.
  • Member ID# – Policy Number of the insurance company.
  • Claim received Date – Claim received date is the date when claim received by insurance from provider or billing company.
  • Payment or denial date – Payment or Denial date is the date when the claim adjudicated or processed.
  • Date of Service – Date of Service is the date when the service is provided to patient from provider.
  • CPT Code – CPT code is the treatment or procedures performed by the provider to patient.
  • Billed Amount – Billed Amount is the amount billed by the billing office or provider to insurance company.

If claim paid, then EOB will have this following information and payment details.

  • Allowed Amount – Allowed Amount is the amount allowed by the insurance company after adjudication of the claim.
  • Paid Amount – Paid Amount is the amount paid by the insurance company to the provider for the service rendered.
  • Patient Responsibility – Patient Responsibility is the amount a patient is responsible for paying that is not covered by the insurance plan. It includes Co-Insurance or Deductible or Copay.
  • Contractual Adjustment – Amount which provider agrees to write off as per the contract between the insurance company and which not suppose to bill the patient.
  • Check#
  • Check date

 

If claim denied, then the EOB will have this following information.

  • Denial Code – A denial code indicates why a claim has been adjusted.
  • Denial Reason – Denial Reason is the explanation of denial codes.

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