Insurance, decoded
Insurance and price are two different things
The price is what a provider charges — and it can vary a lot. Your insurance decides how much of that price you pay, based on your deductible, coinsurance, and network. Knowing how those pieces work is how you spend less. This is general information, not advice — your plan’s exact terms always win.
The words on your bill, explained
Tap any term for a plain definition, a simple example, and why it affects your wallet.
Copay & coinsurance
A copay is a flat fee; coinsurance is your percentage share after the deductible.
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Out-of-pocket maximum
The most you’ll pay in a year for covered, in-network care. Then the plan pays 100%.
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EOB (Explanation of Benefits)
A summary of what was billed and covered. It is not a bill — check it against the bill.
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In- vs out-of-network
In-network providers have agreed rates. Out-of-network usually costs far more.
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Prior authorization
Approval your plan requires before certain care — skipping it can mean a denial.
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When paying cash can cost less
For imaging, labs, physical therapy, and some procedures, a provider’s upfront cash price can beat what you’d pay toward a high deductible. Always ask, “What is the self-pay price if I don’t use insurance?” — and compare.
Why cost is also an access problem
When people can’t tell what care will cost, they delay or skip it — and small problems become expensive ones. Clear prices and a basic grasp of your plan help you actually get the care you need.
Estimate your cost before you go
Plug in your plan’s numbers and a price to see your likely share — and whether paying cash would cost less.
Cost estimator: what would you actually pay?
Enter round numbers from your plan and a price. As you type, you’ll see an illustrative breakdown of your share vs. your plan’s — and whether paying cash might cost less. Everything stays in your browser; nothing is sent or saved.
How to read it: You pay the full price until you meet your deductible. After that, you pay your coinsurance percentage of the rest — until your spending reaches your out-of-pocket maximum, when your plan pays 100% of covered, in-network care.
How this math works
- Remaining deductible = your deductible minus what you’ve already met. You pay the price up to that amount.
- Coinsurance: on whatever is left after the deductible, you pay your coinsurance percent and the plan pays the rest.
- Out-of-pocket maximum: your total share this year can’t go past it. Once you hit it, the plan pays 100% of covered, in-network care.
- Copay: if you enter one, this estimator treats the visit as a copay service — you pay the flat copay (it counts toward your out-of-pocket max) instead of the deductible/coinsurance, which is how many plans handle copay visits.
- Cash price: if you enter a self-pay price, we compare it to your insured share so you can see when paying cash costs less.
Estimate only — not a quote. Real costs vary by plan and contract: separate deductibles, services that don’t count, in- vs out-of-network, and copay rules all differ. Verify with your insurer and provider. No personal or health information is collected; nothing leaves your browser.
Make sense of your EOB
An Explanation of Benefits isn’t a bill. Explore this fictional sample — each highlighted part explains what it means and what to check.
Decode a sample EOB
An Explanation of Benefits (EOB) is a summary from your insurer — not a bill. This is a fictional sample. Hover, tap, or use the arrow keys to move between the highlighted parts and see what each one means.
Evergreen Sample Health Plan
Explanation of Benefits
| Service | Billed | Allowed | Plan paid | You owe | Code |
|---|---|---|---|---|---|
| Office visit (99213) | $250 | $120 | $96 | $24 | — |
| X-ray, wrist (73110) | $200 | $90 | $72 | $18 |
- Amount billed ($450). The provider’s full list price, before your plan’s discount. You almost never pay this whole amount — it’s just the starting point. Don’t panic at this number; what matters is the allowed amount and your share.
- Allowed amount ($210). The price your plan and the provider agreed on. Your share and the plan’s share are both figured from this — not from the billed amount. For an in-network visit there should be an allowed amount. A blank can mean the service was denied or out-of-network.
- Plan discount / adjustment (−$240). The amount removed because your plan negotiated a lower in-network rate. This is money you do NOT owe — the provider writes it off. In-network claims should show a discount. No discount may mean the provider was out-of-network.
- Plan paid ($168). What your insurance paid toward the allowed amount. If this is $0, find out why — an unmet deductible, a denial, or out-of-network care.
- Your responsibility ($42). Your share of the allowed amount — toward your deductible, a copay, or coinsurance. Compare this to the provider’s actual bill. The bill should not ask for more than this (except true non-covered items).
- This is not a bill. An EOB is a summary from your insurer, not a request for payment. The provider sends the actual bill separately. Never pay from the EOB. Wait for the provider’s bill and match its “you owe” to this first.
- Claim number (EVG-2026-0048217). The insurer’s reference number for this claim. Quote it whenever you call member services or file an appeal about this visit.
- Remark / adjustment code (CO-45) (CO-45). Codes explain adjustments and denials. “CO-45” means the charge was above the plan’s allowed amount — a contractual write-off you don’t owe (in-network). “PR” codes mean patient responsibility; a denial code (e.g. “needs prior authorization,” “not medically necessary”) is your cue to consider an appeal. Look up any code on the EOB. If it’s a denial you think is wrong, you can appeal.
Red flags to look for
- A service, date, or provider you don’t recognize.
- Billed as out-of-network when you expected in-network (often: no plan discount).
- The provider’s bill asks for more than the EOB’s “your responsibility.”
- A denial you think is wrong — e.g. “not medically necessary” or “needs prior authorization.”
If a charge looks wrong
- Call the provider’s billing office and your insurer (quote the claim number) and ask them to explain or correct it.
- Don’t pay until the provider’s bill matches the EOB’s “your responsibility.”
- If it’s a denial you want to challenge, walk through how to appeal a denial.
Sample only — not a real EOB and not advice. Every name, ID, and figure here is invented to teach the layout; yours will differ. The Hub collects no personal or health information — nothing is entered or sent.
Denied? Build your appeal plan
A claim denial is often the start of a conversation, not the end. Answer a couple of questions and get a tailored, printable list of next steps for your situation.
Was your claim denied? Walk through your options
Answer a couple of plain-language questions and get a tailored, printable list of next steps. This is general information, not legal or coverage advice — and nothing you choose is sent or saved.
Not medically necessary
The plan says the service wasn’t needed for your condition. This is one of the most appealable denials — your treating clinician’s judgment carries real weight.
Out-of-network (or no referral)
The provider didn’t have an in-network contract, or your plan required a referral you didn’t have. Your rights can differ a lot depending on the situation.
Prior authorization missing
The plan required approval before the service and didn’t have it on file. Often this is a paperwork gap the provider can fix.
Coding or billing error
A wrong procedure or diagnosis code, a duplicate, or a typo can trigger a denial. This is usually a billing fix, not a formal appeal.
Service not covered (exclusion)
The plan says this service isn’t a covered benefit. These are harder to overturn, but exceptions exist.
Deductible / benefit limit (you owe a share)
This often isn’t a denial at all — it’s your normal cost-share because you haven’t met your deductible, or you’ve hit a benefit limit.
I’m not sure why it was denied
You can’t appeal well until you know the exact reason. The denial reason and code are on the EOB or the denial letter.
The usual appeal path
- Get the denial in writing — the exact reason and code, plus your plan’s appeal instructions and deadline (on the denial letter, the EOB, or your member portal).
- File an internal appeal with your insurer before the deadline (often around 180 days, but it varies by plan and state).
- Include your evidence: the denial letter, the EOB, a letter of medical necessity from your doctor, relevant records, and the plan language that supports coverage.
- If the internal appeal is denied, request an external review by an independent third party — for many plans this is a right under federal or state law.
- Keep copies of everything and a log of every call: date, who you spoke with, and a reference number.
General information — not legal, financial, or coverage advice. Appeal deadlines and your rights vary by plan and state (and differ for employer/ERISA plans). Always verify with your insurer and, if needed, your state’s Department of Insurance. No personal or health information is collected; nothing is sent or saved.
Have a question about your care or a bill?
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