What is an Explanation of Benefits (EOB)?
An Explanation of Benefits (EOB) is a document that explains how a claim was processed under a benefit plan. It outlines the cost of services, how much an insurer or secondary benefit plan paid, and any remaining amount you may owe.
An EOB is not a bill. It helps you understand how your benefits were applied and how your claim was processed. Understanding your EOB can help you check for errors, ensure that your payments are correct, and track your healthcare spending.
When and Why do you receive an Explanation of Benefits (EOB)?
An EOB is typically produced any time a claim is processed. They can come from a major medical carrier or, if you’re a member, from ClaimLinx. EOBs are created after a claim is processed. It is important to check the EOB for any services rendered to ensure the claim was processed correctly and to see if there is any remaining balance.
Most major medical insurance carriers have timely filing requirements, which set a deadline for submitting claims. If a claim is not submitted within the required time frame, the plan may deny it. In this case, the member can be left responsible for costs that might have been covered otherwise. This is another reason it’s important to verify you have received an EOB for services.
How to Read an EOB from a Primary Carrier
Reading an EOB from a major medical carrier can be confusing. The Center for Medicare and Medicaid Services has a helpful guide on reading the documents.
Remember, an EOB is not a bill. Your health plan carrier sends an EOB, either electronically or in the mail after your visit with a provider. It will show you the total charges for your visit and how much you and your health plan owe. You can also use it to track how you and your family use your coverage.
In addition to receiving an EOB, you may also receive a bill from the provider. Keep these documents for your reference until the final amount is resolved.
Here’s an example of an Explanation of Benefits
Understanding the Terms on Your EOB
General information about you and your health plan
The explanation of benefits includes information about:
- You (the patient)
- Your health plan
- Who provided your care, and when it was provided
- A reference number called the claim number
- The person who gets reimbursed for any over payments, called the payee
It will also list your health plan’s phone number. Call your health plan if you have questions about finding a provider or what services they cover.
Details about your claim(s)
The explanation of benefits gives you details about your care, like:
- The Date of Service– specific date or range of dates the services were provided.
- Service Description– The health services you received, like a medical visit, lab test or screening.
What was charged and how it was covered
The explanation of benefits lists the cost of your care, and how much your health insurance company will pay.
- Provider Charges– The amount your provider bills for the visit.
- Allowed Charges – The amount your provider will be paid; this maybe not be the same as the Provider Charges.
- Paid by Insurer– The amount the health plan with the major medical carrier will pay to the provider.
- What You Owe– The amount you owe after your insurer has paid everything else. Payments to the provider may not be subtracted from this amount.
- Remark Code– Note from the health plan that explains more about the costs, charges, and paid amounts for your visit.
Check for Both EOBs before Paying
What You Owe, or Patient Balance, is the amount you owe after your primary insurer has paid. However, the primary carrier EOB doesn’t include any secondary coverage. It’s important to wait for the EOB from ClaimLinx for the final determination of what is owed.
In addition, you may have already paid for part of the Patient Balance. The Explanation of Benefits only shows what you owe, not if you’ve already paid for it.
ClaimLinx Sample EOB
This is an example of the ClaimLinx Explanation of Benefits (EOB) available in the secure member portal. EOBs are available on the secure portal once they have been processed.
Reading a ClaimLinx EOB
Remember this is not a bill. It is an explanation of the amount the secondary benefit plan covers. It helps you understand how much the complete health plan covers and what you’ll pay when you get a bill from your provider.
Key Details to Review on the secondary EOB
Just like an EOB from a major medical carrier, there are important terms to be aware of. The most important section on the ClaimLinx EOB is the Claim Summary section. This section explains how much the secondary benefit covers and the final amount the member owes.
- Total Amount Covered– The amount eligible for benefit, after the primary payment and discount.
- Total Paid by Plan– The amount the secondary MERP benefit covers and will be sent to the provider.
- Patient Responsibility– The amount the member is responsible for at the time of the service or when a bill arrives.
View EOB(s) on the Member Portal
If employees have questions, the Member Support Specialists are available to explain and/or review the claims. To view EOB(s) please login to the secure Member Portal.
Who should I contact with questions?
You can reach our Member Services team by phone or email for help with portal registration, EOB questions, or mailing requests. Contact information is available on our Contact Us page.
We’re Here to Support You
You can reach us at (800) 858-1772 or by email at claims@claimlinx.com.
Thank you for choosing ClaimLinx. We appreciate your continued trust in our team as we work to make your benefits experience clearer, faster, and more convenient.
At ClaimLinx, we’re committed to providing our members and providers with the best possible service. Moving EOBs to the online portal is just one way we’re making claims processing more efficient, secure, and environmentally responsible.
