Understanding Your Explanation of Benefits (EOB)

An EOB is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.  Below is an example of an EOB a student on the Bowdoin student health insurance plan would receive.  Under the sample EOB are definitions of terms.

COLUMN EXPLANATION:

 

  • Service - a descriptive term for the submitted medical service or procedure.

 

  • Dates of Service - the actual date the medical service/procedure was performed. This is not the date it was billed or processed.

 

  • Proc Code - the actual AMA CPT® that was submitted by the Medical Provider. 

 

  • Amount Claimed - the actual amount the Medical Provider charged for the service/procedure.

 

  • Ineligible - the required coinsurance (if a PPO provider is used) OR any amount that exceeds the Usual and Customary (if an Out-of-Network Provider is used) and is therefore not covered under the policy. The Ineligible amount will be included in the Patient Balance.

 

  • Discount - any applicable PPO discount that varies depending on the Providers contract with UnitedHealthcare.

 

  • Total Covered- the Amount Claimed minus any Discount or Ineligible amounts.

 

  • Copay - the amount per visit that the plan requires you pay. This is in addition to the Deductible. This amount is subtracted from the Total Covered and will be included in the Patient Balance.

 

  • Policy Deductible - a specified amount of money that the insured is responsible for before the insurance company will pay a claim.  If the insured has paid some, but not all of the deductible, the unsatisfied amount will be subtracted from the “Total Covered” before any coinsurance is calculated.

 

  • Total Benefits - the amount paid by the Insurance Company.  This amount should match the Check Amount unless the EOB is a correction and a previous amount had already been paid.

 

  • Patient Balance - the amount the insurance company estimates you will be required to pay for Medical Services. This will include any amounts listed in Ineligible and Deductible columns.

 

  • Remark Code - explains in further detail how the Insurance Company processed a particular charge.  The full remark can be found under the “Remarks:” heading. Match the Code to the appropriate Remarks text below. There may be multiple remarks per line item.