Explanation of Benefits (EOB)
A statement that tells a patient and their provider what the allowable amount is for the patient’s claim. Of the allowable amount, the EOB explains what the patient owes and what the insurance company will pay, if anything. It tells the patient if what they owe is a co-payment, co-insurance, or if they are paying the entire allowable amount and how much of what they owe is applied to their deductible and out-of-pocket maximum.
SERV DATE
SERV Date is the date you received the services. Maybe you had a check-up or maybe you visited the doctor for a cough and fever. The SERV date is the date when that happened.
POS
POS means Place of Service and indicates where you had the services done. For example, your doctor’s office or a hospital.
PROC
PROC, or procedure code, is a code or description of the service you received. Listed here are the CPT codes. CPT stands for “current procedural terminology.” These codes indicate what services were performed. These may be numeric codes, descriptions, or both.
BILLED
The BILLED amount is the amount charged by the provider for each service.
ALLOWED
The ALLOWED column represents how much the insurance company has agreed to pay for a particular service. Be aware that the amount billed from the provider is almost always higher than what the insurance companies pay for those services.
DEDUC, COPAY, COINS
Deductible, co-pay (not shown in this example), and co-insurance columns are the responsibility of the patient. Most insurance plans require some form of a “deductible”, or a set dollar amount that the individual, or the individual and family, are responsible for each year (on top of any monthly premiums paid to the insurance company). “Coinsurance” is a percentage of the allowed amount. This can be a confusing aspect of your benefits because the insurance company may have different coinsurance percentages for different types of services. Copays, you’ll recall, are fixed dollar amounts and can apply both before AND after meeting your deductible. You’ll want to refer to your SBC to find out your copay, coinsurance, and deductible responsibilities.
REASON CODES In this example, in this column we can see “reason codes” that may explain why the claim is being paid the way it is. There’s usually a glossary on the EOB that explains the codes.
REASON CODES In this example, we see a "reason codes" column. There’s usually a glossary on the EOB that explains these codes (which may explain why the claim is being paid the way it is).
GRC/RC-AMT The difference between the billed amount and the allowed amount can be seen in this column. Sometimes this is called the “discounted amount.” This difference is “written off” by the provider and neither the insurance company nor the patient is responsible for this portion.
PROV PD This final column represents the amount the insurance company paid to the provider. These numbers represent the allowed amount minus any deductibles, copays, and co-insurance for which the patient is responsible.