Reading an Explanation of Benefits with a client

An Explanation of Benefits (EOB) is not a bill. It shows what the provider billed, the plan's allowed amount, what the plan paid and what the patient may owe.

Walk through it in this order

1. Match the EOB to the provider bill by date of service and provider name.
2. Compare the billed amount with the allowed amount. For in-network care the patient generally shouldn't owe the difference.
3. Read the remark or reason codes. A denial for missing information is often fixable with a corrected claim.
4. Check whether the deductible and out-of-pocket totals look right for the plan year.

When to question it: duplicate lines, services the client doesn't recognize, out-of-network processing for an in-network provider, or emergency care billed as out-of-network — which may be protected under the No Surprises Act.

Sources: CMS medical bill rights (opens in a new tab); HealthCare.gov glossary (opens in a new tab).