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FAQ: What Is An Explanation Of Benefits?

Typically an insurance policy will have a deductiblecoinsurance or copayment, and an out-of-pocket maximum. Every insurance plan is different. You may be responsible for paying your deductible when you receive certain services. The same applies to copays and coinsurances. On the other hand, your insurance plan may cover some services completely. All of this information will appear in your explanation of benefits. So, what is an explanation of benefits, exactly?

What Is An Explanation Of Benefits

When you receive healthcare services, your insurance company gets a claim from your doctor for each visit. Once the claim is processed, you will receive an explanation of benefits in the mail from your insurance company.

The reimbursement is a set amount based on the services that are performed. The set price for a service doesn’t change. The amount the insurance company will pay and the amount the patient is responsible for paying can change. 

What Is An Explanation Of Benefits

Sometimes the insurance company is responsible for paying way less than the patient, or vice versa. It all depends on your plan. If a patient meets their OOPM, their insurance company is responsible for paying all medical costs for the rest of the year. This means the patient is not responsible for making any payments.

The total reimbursement a provider gets = insurance company payments + patient payments. 

  • For instance, your EOB says you owe your doctor $11.55 as your coinsurance charge, while the insurance company owes them $89.45.
  • But if your EOB states that you owe a $45 copay on a $70 charge and you decide not to pay, the provider is only going to receive the $25 payment from your insurance company for the care they gave you

Typically, it takes 4-6 weeks to receive an EOB in the mail. Some insurance companies send them online. Most EOB info will appear on any bills as well. Unfortunately, we cannot provide a copy of your EOB. However, you can contact your insurance company to get a copy.

For more information about health insurance, click here.

About The Author

Jaime Curl

I've explored many different fields within physical therapy, including acute care and oncology at Troy Beaumont Hospital, elementary through high school levels in the Troy School District, and outpatient physical therapy. As the office manager and marketer, I am able to combine my love for health and exercise science with my people skills, all with a dash of marketing and personal training. My hobbies include spending time with friends and family, baking, crafting, and watching my favorite movies or tv shows.

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