What is an Explanation of Benefits? After a health care provider sends a claim to your health care plan, the plan, or a benefits administrator, will send you a copy of a document called an Explanation of Benefits (EOB). An EOB essentially tells you what your plan paid the health care provider and what portion, if any, of the charges you are responsible for paying. Since all health care plans are not the same, your EOBs will look different, depending on your insurance company and even your plan. Here is a summary of what kind of information may be included on an EOB: General information, such as your plan group number, the plan’s name, the name of the insured, the name of your employer and the insured’s I.D. number – which is usually a Social Security number. Name of the health care provider who provided the service. The name of the patient, either you or a covered family member. The date the service was performed. A general description of the service performed. Some typical descriptions are "Office Services," "Laboratory," or "Special Services." The date the claim was processed and a claim number. You’ll need the claim number if you need to discuss the EOB with your benefits administrator. Procedure code. This is a standardized code for specific health care services. Claims specialists use the code to determine if the fee your provider charged for a service is "reasonable and customary" compared to providers performing similar procedures in your geographic region. The fee your provider charged for the service. There may also be a second, discount fee that the provider and your health care plan negotiated. Covered expense, or the amount your plan will cover for the particular procedure. This is sometimes shown as a percentage. The amount of co-payment or co-insurance that you owe. The amount of the charge applied to your deductible. Often the EOB will also show a cumulative total that you’ve paid toward your deductible for the calendar year. Payable benefit, or how much your plan paid the provider. Maximum lifetime benefit. If you have a maximum, the EOB may show the amount of claims paid on your behalf since you’ve had the health care plan. Notes section that further explains coverage. Phone number to call if you have questions. Steps concerning how to appeal a decision is usually on the back of the EOB. There is also information about what steps the plan has taken to comply with the Employee Retirement Income Security Act (ERISA), a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans. Health care plans established for government and church employees may have different rules, and sometimes additional ERISA guidelines are imposed at the state level. ERISA requires plans to provide participants with information about plan features and funding, requires plans to establish a grievance and appeals process for participants to get benefits from their plans, and gives participants the right to sue their health care plans. If you have questions about coverage, be sure to call the phone number on the EOB or refer to your plan information. © 2004 by Roger Lacocoa,  Affordable Health Insurance Quotes. ~~~~~~~~~ About the author: Roger Lacocoa is a professional consultant with Affordable Health Insurance Quotes, specializing in the areas of health, life and disability insurance. Disclaimer: All content in this website is provided for educational purposes only. The publishers of this website do not give any warranty as to the accuracy or completeness of the content on same website. No part of this website or any material appearing on the site may be reproduced, stored in or transmitted on any other website without written permission. All content is original and copyrighted.