Tool
EOB decoder
Last reviewed · Educational use only
An Explanation of Benefits is the insurer's receipt for a processed claim. It is not a bill. Select any underlined part of this sample to see what it means.
Explanation of Benefits
THIS IS NOT A BILL
THIS IS NOT A BILL
| Service | ||||||||
|---|---|---|---|---|---|---|---|---|
| $2,400.00 | $1,500.00 | $900.00 | $0.00 | $400.00 | $100.00 | $400.00 | A1 | |
| Radiologist reading (73721-26) | $350.00 | $230.00 | $120.00 | $0.00 | $0.00 | $24.00 | $96.00 | A1 |
| Contrast kit (A9579) | $90.00 | $0.00 | $0.00 | $90.00 | $0.00 | $0.00 | $0.00 | B7 |
Select an underlined item. Each one explains a field you will see on most EOBs, and what to check.
Every EOB field explained
- Member
- The subscriber or dependent who received care. Check it is the right person; family members share an account but each has their own claims.
- Claim number
- The insurer's claim number. Quote it whenever you call the insurer or the provider. One visit can produce several claims (facility, radiologist, lab).
- Provider and network status
- Who billed, and whether the plan treated them as in or out of network. If this says out of network and you expected otherwise, ask: the provider may have billed under a different location or tax ID.
- Service and code
- The service and its CPT or HCPCS code. The same imaging study often shows up twice: the technical part from the facility and the professional reading from the radiologist (modifier 26).
- Amount billed
- The provider's full charge. Nobody with insurance normally pays this amount for in-network care.
- Network discount
- The part of the charge the in-network provider agreed to write off. You do not owe this. Insurers label it plan discount, network savings or provider adjustment. On the provider's remittance it is CO-45.
- Allowed amount
- The contracted price for the service. Everything you owe for in-network care is calculated from this number.
- Not covered
- Amounts the plan did not cover. Read the remark code: it might be something you owe (a plan exclusion) or something the provider must write off (a bundled item, as with code B7 here).
- Deductible
- The part applied to your deductible. You owe it to the provider. The deductible resets each plan year.
- Coinsurance
- Your percentage of the allowed amount after the deductible: here 20% of what was left. You owe it to the provider.
- Plan paid
- What the insurer paid the provider. If it says the payment went to you, you are expected to pay the provider.
- Remark
- Short codes explained at the bottom of the EOB. They tell you why an amount was reduced or denied. Providers see related CARC/RARC codes on their remittance.
- Remark code explanations
- Each insurer uses its own remark codes on member EOBs. The wording matters: "provider may not bill you" means the amount is the provider's to write off.
- You may owe
- Your total responsibility: deductible + copay + coinsurance + amounts you owe as non-covered. Here $400 + $100 + $24 = $524. An in-network bill above this amount is a red flag.
- Deductible and out-of-pocket progress
- Your progress toward the deductible and out-of-pocket maximum for the plan year. Once out-of-pocket reaches the maximum, covered in-network care is paid in full.
Checking an EOB against a bill
- Match the date of service, provider and claim to the bill.
- Find "you may owe" (also "patient responsibility" or "member responsibility"). An in-network provider's bill should not be higher than that.
- If the provider bills more, ask whether they billed the plan, whether a payment is still pending, and whether they have the right insurance on file.
- For denials, read the remark code and call the insurer before paying. Many denials are fixable billing errors.
- Keep EOBs for the year; they are your record of deductible and out-of-pocket progress.
Billing pros
The provider receives the same information as an electronic remittance advice (ERA, X12 835). How the EOB fields map:
| EOB field | 835 location |
|---|---|
| Claim status (paid as primary, secondary, denied, reversed) | CLP02 (1 primary, 2 secondary, 3 tertiary, 4 denied, 22 reversal) |
| Total billed / paid / patient responsibility | CLP03 / CLP04 / CLP05 |
| Payer claim number | CLP07 |
| Service line: code, billed, paid | SVC01–SVC03 |
| Allowed amount | AMT*B6 |
| Network discount | CAS*CO*45 |
| Deductible / coinsurance / copay | CAS*PR*1 / CAS*PR*2 / CAS*PR*3 |
| Remark codes | LQ*HE (RARC) at line level, MOA/MIA at claim level |