By Sonya Sellmeyer, Consumer Advocacy Officer for the Iowa Insurance Division

Navigating the complexities of healthcare can be a daunting task. One such document that plays a crucial role in understanding healthcare costs and coverage is the Explanation of Benefits. 

An Explanation of Benefits, or EOB, is a detailed statement sent by a health insurance plan to a policyholder after a claim is filed. This document outlines the costs incurred during a specific medical service or procedure and explains how the health plan contributes to covering those expenses.  

At the top of the EOB, you'll find essential details such as the patient's name, policy number, the date of service, the physician’s name, and the type of service rendered. This information ensures that the document is correctly associated with the individual's healthcare policy.  An EOB may contain information on more than one claim or patient. 

The amount charged section outlines the total charges for the services, the amount covered by insurance, and any remaining balance due from the patient. It also details the copayment, coinsurance, and deductible amounts, as well as any amount not covered or denied.  If a service is denied, the document will include a code explaining the reason.  A claim may be denied for a lack of information, out-of-network provider, no prior approval for a service or procedure, the service is not covered under the policy, or an error. If there is a discrepancy or you disagree with how a claim was settled,  call the customer service number on your insurance card and ask for an explanation.  If you are not satisfied, you may need to file an appeal.  Your rights regarding an appeal may be found on the EOB.  

An EOB is not a bill.  Wait to pay any responsible amounts after receiving a bill from the appropriate provider.  Review all bills from the provider to ensure they are accurate with the benefits paid by the health insurance plan.   

An EOB is a document that plays a pivotal role in understanding healthcare costs and coverage. By familiarizing yourself with the components of an EOB and regularly reviewing these statements, individuals can take control of their healthcare finances, and ensure the accuracy of claims.  The EOB is more than just a statement; it is a tool that empowers individuals to navigate the complex landscape of healthcare with confidence.