Understanding and Interpreting Explanation of Benefits (EOB)

Why is an EOB so important?

An EOB is crucial for indicating whether and how a claim was paid as well as any outstanding balance that the patient may be responsible for. An EOB gives patients the chance to confirm that they are being charged for a service or treatment that they have actually received and that the indicated amount is reasonable.

An EOB provides you with crucial information such as the date of service, the procedures conducted, and also the amount processed by the insurance company. It also shows if there are any copays or deductibles for the procedures performed. One section that is important for patients is the amount the patient needs to pay out of pocket, or patient responsibility. This includes deductibles, co-pays, and coinsurance payments. The EOB shows exactly how much of the payment the insurance plan covers and how much the patient is to pay as per the plan benefits. Additional significant data, such as codes for pending status or claim denial, can also be found in the explanation of benefits. Basically, an EOB provides clear information on the limitations of the plan and any balances that are due. 

What gets included in an EOB?

• Dentist name

• Claim number

• Patient identifiable information such as policy number, group number, and date of birth

• Treatments performed

• Procedure description

• The date the procedure was performed

• Dentist’s fees

• Amount that was approved and processed by the insurance company

• Service and coverage information

• Deductibles

• Co-pays

• Coinsurance

• Coordination of benefits information

• The portion of the annual maximum that has been used

• CDT Code (Current Dental Terminology Code)

• Details on resubmissions needed

• Codes for pending status or claim denial

Why is it important for patients to read through their EOBs?

With all the codes and numbers, EOBs can appear complex, but it is important for patients to read through the EOB in order to make sure that they have only been charged for services that were received. A claim may occasionally be submitted by the provider which may not contain all the details required by the insurance company to finish processing it. Therefore, understanding and reading through the different sections of an EOB is pivotal in finding and avoiding many billing errors.

Reading through important information like claim codes for pending status, requests for more information, or the denial status which are provided at the bottom of the statement also gives patients the opportunity to follow up with their provider in case any additional information is needed. Patients can be certain that they are paying the correct amount by comparing the patient responsibility amount mentioned on the EOB with the provider's billed amount. An EOB helps ensure that the insurance benefits are being utilized to their full potential.