What to do
Find the five numbers
Billed amount, allowed amount, plan paid, your responsibility, and any adjustment or discount. Everything else on the page is context for these.
Read the remark or reason codes
Small codes in the margin explain why something was reduced or denied. The key is usually on the back or the last page.
Compare it to the provider's bill
If the provider is billing you more than the EOB says you owe, that is a balance-billing question, not a coverage question.
Check that the codes match what happened
A wrong procedure or diagnosis code produces a denial that has nothing to do with your coverage. Ask the billing office to compare against the operative report.
Treat a denial on an EOB as a denial
If a line is denied, appeal rights attach and a clock starts, even though the document does not look like a denial letter.
Where the EOB goes
On a family policy the EOB is usually mailed to the policyholder, describing the care by procedure and diagnosis. If that is a problem for you, ask about confidential communications before you use the benefit rather than after.
Common questions
- Is an EOB a bill?
- No. It is a statement of how the claim was processed. The bill comes from the provider, and the two should agree about what you owe.
- The EOB says I owe less than my provider is billing. Which is right?
- For an in-network provider, the EOB generally governs and the extra amount may be improper balance billing. Raise it with both the provider and the plan.