Explanation of Benefits (EOB) Overview

The Explanation of Benefits (EOB) is how the payer communicates with the clinic once the claim has gone through the adjudication process. The EOB is extremely important as it tells the clinic what the insurance is paying and provides the reasoning behind the decision. An EOB can help direct the biller on how to resolve the additional balance through write-offs, patient payments, or secondary insurances. The EOB can arrive as a paper document or electronically as an 835 ERA file.

The following questions are answered in an EOB:

• What client is the payment for?
• What is the Date of Service?
• What CPT codes were paid?
• How much did the insurance pay?
• How much was adjusted?
• How much is owed by the client?
• What is the reasoning for the payment/adjustment amount?

Sample EOB

Let’s review this example explaining how to read an EOB’s detail page. Please note that detail pages can be several hundred pages in length.

8. Billing Provider’s NPI
9. Date(s) of Service
10. Units for the specific CPT code
11. CPT Code
12. Codes that describe the type of pricing on the claim
13. Original Charge Amount
14. Allowed Amount (Contracted Rate) for each the specific CPT code
15. Adjustment Amount
16. Code that describes why the provider cannot charge the client the amount in field 15
17. Client Responsibility Amount
18. Code that describes why the member is liable for the amount in field 17
19. Other payment amounts (i.e. other insurance payments)
20. Amount paid to the Billing Provider, unless the payment is made to the client. Payments made to the client are denoted by an asterisk (*)
21. Codes that correspond to the messages at the bottom of the Detail pages.
22. Claim messages
23. Additional claim messages