How to read your EOB

Learn more about what’s in an explanation of benefits (EOB) and how to read the documents sent along with it.

What is an EOB?

An explanation of benefits (EOB) is a list of claims your insurance company received from your providers. It’s not a bill – it’s a document your insurance company sends you after a medical claim has been processed.

It breaks down the cost for claims received by your providers, how much your insurance plan covered, and how much you may still owe.

What you'll find in your EOB

Provider charges

Find out how much of what your provider charged was covered and at what rate.

The covered amount is the portion of the services covered by your insurance plan.

The allowed amount is the maximum amount your insurance will pay for a service and is found in "Claim Details" in the "Allowed Amount" column.

Insurance payments

You’ll learn how much of your care was covered by your insurance.

The paid amount is the amount paid by your insurance company to the health care provider.

Reason codes may be included when changes are made to the cost of your services due to contractual adjustments or negotiated rates.

Remaining balance

Your EOB is not a bill, but you may still have a balance for a claim we received.

If you do owe on a service, your EOB will show how much, but you’ll be billed by your provider – not your insurance company.

Your EOB will explain how close you are to meeting your deductible as well as break down how much you may owe for each individual service.

Check for errors

It's important to make sure the information on your EOB, such as claim details and services you received, are correct.

Check the following information listed under the "Overview" and "Claim Details" sections of your EOB carefully for accuracy:

You personal details, such as your name and subscriber ID
Billed amounts from your health care provider
Service dates your provider listed in your claim match up to the dates you were seen for care
Payments made from your insurance company to your provider
No additional services were added to your claim that you didn't receive from your provider

You can find your health plan's details in your Benefit Booklet on your Blue Connect℠ member portal.

Identifying your documents

An EOB comes with a few pages. Here’s how to review the documents you receive.

Overview

On the overview page you’ll find the highlights of your EOB, including your name, subscriber ID, name of your health plan, service date, and general claims details.

If your claim includes a reason code, you’ll find it here with a red icon pointing you to more information about the alert.

You’ll also find the covered amount of your services on this page.

Your benefit year summary

This page of your EOB shows your health care spending for the current benefit year.

That means you'll find details about your deductible and out-of-pocket maximum for yourself, your spouse, and your dependents.

You'll find how much of your deductible and out-of-pocket maximum has been satisfied during the benefit year.

Claim details

The claim details page further simplifies what’s highlighted in the overview. It includes provider name, claim number, service date, and payment details.

Here you’ll also find the total amount paid per service under Blue Cross NC Paid, as well as the allowed amount for each of those detailed services.

The claim details page also shows the amount remaining you may owe for a service.

Appeals

If a denied claim is listed on your EOB, you can file an appeal. The appeals page explains the steps you'll need to take to appeal a claim.

You can find the appeals forms you need on our Member Forms page. When you file an appeal, your doctor will need to send extra information to your insurance company showing that the service, treatment, or medication is medically necessary for you.

Learn About Appeals

Other terms in EOBs

You'll find many health care terms on your EOB, including:

Allowed amount – the maximum amount a plan will pay for a covered service.
Amount Blue Cross NC paid – the amount your insurance company paid of the total cost.
Amount satisfied – the amount you have paid toward your deductible
Billed amount – the amount your provider billed your insurance company.
Copayment or coinsurance amount – any copayment (fixed amount) or coinsurance (percentage of total cost) that you paid.
Deductible – the amount you must meet before your insurance pays.
Member savings – how much weren't required to pay. You save money because your insurance company works to negotiate prices, so your provider is only allowed to charge a certain rate.
Not covered – any amounts for services that weren't covered.
Plan's limit – the in-network and out-of-network deductible amounts you owe.
Reason code – any reason code or adjustment code that may apply to your claim for a benefit determination made by your insurance provider.
Service date – the date you received treatment or care.

Learn More Health Insurance Terms