What information does an EOB typically include?

• A. A statement from the insurer to the patient detailing what was paid, what was denied, and why.
• B. A summary of monthly premiums.
• C. Provider contact information for scheduling.
• D. A notice of enrollment eligibility.

Answer: (A)

An Explanation of Benefits is the insurer’s summary to you after a claim is processed, showing what happened with the claim. It explains the amount the plan paid for the service, any portion that was denied or reduced, and the reasons behind those decisions. It also lists the allowed amount for the service, your responsibility (such as deductible, coinsurance, or copayment), and any remaining balance you might owe to the provider. The EOB uses codes or notes to explain why something was denied or adjusted, such as services not covered, not medically necessary, or outside the benefit you have. This document helps you understand how your benefits were applied, and what you owe, separate from the monthly premium statements or enrollment notices. Remember, the EOB is information about the claim outcome, not a bill, although it may accompany a bill from the provider.