| Thu, Aug 14, 2014 @ 09:00 AM

Decode Your Explanation of Benefits (EOB)

Posted by Medicare Made Clear

explanation of benefitsYou’ve seen it. Your Explanation of Benefits (EOB). It usually comes in the mail a few weeks after you fill a prescription or receive health care services from a doctor, hospital or other health care providers. Some people file it away without ever looking at it because they don’t know what they’re looking for. An EOB is not a medical bill. It’s a summary of services received.  When you receive the EOB, it’s important to check it to make sure the information is correct.

Each insurance company and Medicare EOB may be slightly different. But the typical EOB will usually contain some variation of the following information.

Medicare Part D Prescription Drug Coverage EOB:

  • A summary of the claims processed since your last EOB
  • A summary of your year-to-date costs in the plan, information about the person’s current drug payment stage (the deductible, initial coverage, the coverage gap, or catastrophic coverage), and your total out-of-pocket and drug costs
  • A record of your total out-of-pocket costs and total drug costs transferred from your previous plan (if you changed plans in the current year)
  • Any adjustments for a reversed claim or a correction to a clerical error to your total out-of-pocket costs and total drug costs that aren’t shown in a previous EOB
  • Any updates to the drug plan’s formulary that will affect drugs you’re currently taking

Doctor, Hospital or Other Health Care Provider Visit EOB:

  • Your name, address and policy or group number
  • Your doctor or hospital name and address
  • Dates of your doctor visits or hospital stays
  • A brief description of the services provided, including consultations, hospital rooms, drugs, supplies, equipment, etc.
  • A CPT code used to describe the service the doctor or hospital provided
  • The fee your doctor or hospital billed your insurance company
  • Amount that is allowed to be charged set by a preset schedule; amounts are considered “usual and customary” to the specific service
  • How much your insurance company actually paid your doctor, provider or hospital for services
  • How much you may have to pay your doctor or hospital for services. This could include any deductible for the year, co-payments and any charges for services your insurance plan does not cover
  • Reason why a service has been denied
  • Your deductible or amount you pay before insurance benefits kick in
  • Your co-pay or amount you are required to pay when receiving services from a provider, sometimes paid upfront at the time of appointment
  • Your benefit amount or the percentage of the bill the insurance company will pay for the service

View a sample hospital stay EOB with full details.

If any of the information on your EOB is incorrect, it could be a clerical error—or worse. Someone may have illegally used your medial identity. If you have any questions about your EOB, call the phone number listed on the form to talk to a customer service representative.

For more information, explore MedicareMadeClear.com or contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048.


Your Explanation of Benefits: AARP.org

Understand Your Explanation of Benefits: CMS.gov

How to Protect Yourself from Medical Identity Theft: AARP.org

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