The EOB Interpreted

If you have ever feltl frustrated or confused over the many terms on an Explanation of Benefits (EOB) form, you are not alone. Entries for "encounter fees," "amount allowed," and "amount ineligible" and other fields can frequently be misinterpreted. A straightforward explanation and reference of commonly-used terms found on the EOB can be very useful.

1. "Check Distribution" lists those providers who you have authorized to receive payment for your benefits, and other parties who received payment for services specified.

2. "Service Date(s)/Provider Service Code/Description" lists the dates of service provided and concise description. A code may also be listed, if applicable.

3. "Amount Charged" is service or treatment fee charged by the provider.

4. "Amount Allowed" are the charges after any discounts and ineligible amounts have been taken out.

5. "Deductible" is the amount you must pay before your benefits are paid. Based on your plan, you may need to pay a separate deductible for prescription drugs.

6. "Discount" is the special rate reduction in charges that you, as a patient, do not pay. Preferred Provider Organizations (PP), OpenAccess (POA), and Point-Of-Service/Primary (POS/Primary) plans commonly agree with the insurer on special rates.

7. "Encounter Fee" is your charge for each one of your visits to a PPO, POS/Primary, or POA participating physician's office that is non-emergency-based. If you have a POA plan and visit a PPO physician, an encounter fee will not apply for that visit. However, encounter fees do apply to POA participating physicians.

8. "Coinsurance" is the amount that represents the percentage of covered charges you are responsible for.

9. "Benefit" is the amount payable to you, or your provider, or both you and your provider, after deducting the coinsurance percentage, deductible and encounter fee. Other adjustments may apply such as ineligible amounts, and special conditions. These will be defined in the "EXPLANATION OF CODES" on the lower left section on the EOB.

10. "Amount Ineligible" is either the amount that is not covered by your plan or the amount that was charged before and counted for. If this figure was assigned a cost, you will be able to read more about it in the "EXPLANATION OF CODES" section on the lower left side.

11. "Codes" reference any items listed in more detail in the "EXPLANATION OF CODES" section on the lower left side.

12. "Prescription Accumulated Deductible" is the calendar year accumulation of prescription drug deductible amounts.

13. "Benefit, Other Coverage, Adjustments, Amount of Payment" box lists the amount payable to you, or your provider, or both you and your provider, after deducting the coinsurance percentage, deductible and encounter fee; secondary payor benefits paid by Medicare, other health insurance, auto insurance or self-funded plans; any adjustments made to reduce or increase payable benefits; and the total reimbursement for services rendered.

14. "Accumulated Deductible Amount" is your accumulated calendar year deductible amounts.

15. "Accumulated Coinsurance Amount(s)" is your accumulated calendar year coinsurance amounts.

If you are unsure about any portion of your EOB, do not hesitate to contact your insurance provider for a detailed explanation.

Sources:

Trust Markets: How to Interpret the Explanation of Benefits (EOB)

Medical Billing and Coding For Physicians: Billing & Coding For Physicians: Billing Terms Explained - EOB Terms