How to Read Your EOB (Explanation of Benefits)

Written by Aptiva Health Editorial Team · Reviewed by Eric Lowe, Healthcare Consultant · Editorial & review standards · How we research

What an EOB is — and what it is not

An Explanation of Benefits (EOB)A summary from your insurer showing what was billed, what the plan paid, and what you may owe. It is not a bill. is a summary your health insurer sends after a doctor, clinic, or hospital files a claimA request your provider sends to your insurer to be paid for the care you received. for your care. It is not a bill. You doA medical doctor — "MD" or "DO" — with four years of medical school plus a multi-year residency in a chosen field. not pay your insurance company from it. It is a receipt-and-explanation showing what was charged, what your plan paid, and what you may still owe the providerAnyone licensed to give you medical care — a physician, nurse practitioner, or physician assistant. Clinics use "provider" as a catch-all for whoever is caring for you..

If you ignore your EOBs, you give up one of your best tools for catching billing mistakes — and billing mistakes are common.

The key lines, decoded

Most EOBs use slightly different wording, but nearly all include these fields:

• Billed amount (or “charges”). The provider’s full list price. This is almost never what anyone actually pays.
• Allowed amountThe most your plan will pay for a covered service — the rate it negotiated. You may owe a share of it, but usually not more.. The discounted price your insurer and the provider agreed on. For in-networkProviders and facilities that have a contract with your plan, usually at lower negotiated prices. care, this is the number that matters.
• Plan paid / insurance paid. The portion your insurer covered.
• Patient responsibility. What you may owe. This is split into:
• DeductibleThe amount you pay out of pocket each year before your plan starts sharing most costs. Until you reach it, you usually pay the full negotiated price for covered care. — the amount you pay before your plan starts sharing costs.
• CopayA flat fee you pay for a specific service, like a doctor visit or a prescription. It can apply even before you meet your deductible. — a flat fee (for example, $40 for a visit).
• CoinsuranceThe share of a covered cost you keep paying after you meet your deductible, written as a percent. Your plan pays the rest. — your percentage share after the deductible (for example, you pay 20%).
• Not covered / denied. Anything the plan refused to pay, usually with a short reason code.

How to use it

1. Match it to the bill the provider sends you. The “patient responsibility” on your EOB should match the bill. If the bill is higher, call and ask why.
2. Check the dates and services. Make sure you actually received what’s listed. Duplicate charges and wrong dates happen.
3. Read the reason codes. If something was denied, the code tells you why — and whether it might be appealed (see our appealsA formal request asking your insurer to reconsider a denied claim. Many denials are overturned. article below).
4. Watch for “out-of-networkProviders without a contract with your plan. Your costs are usually higher, and some plans do not cover them at all.” surprises. If a provider you didn’t choose (like a lab or an anesthesiologist) was out of networkThe group of providers and facilities your plan contracts with. Staying in-network usually costs you less., you may have protections under the No Surprises ActA federal law that protects you from many surprise out-of-network bills — especially for emergency care and for out-of-network providers treating you at an in-network facility..

When to speak up

If the numbers don’t add up, call the number on your EOB. You have the right to ask for a plain-language explanation. Keep notes: date, who you spoke to, and what they said.