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In this video, we’ll discuss what an Explanation of Benefits is (sometimes also known as an “EOB”) and why it’s important. We’ll also talk about when you will receive an Explanation of Benefits, and how to read it. Lastly, we’ll explain what to do if you see something on your Explanation of Benefits that doesn’t look right, and how you can help protect against fraud and identity theft.
LET’S EXPLAIN Your EXPLANATION of BENEFITS
Some people feel a little confused when they get an Explanation of Benefits in the mail. But it’s actually, a great way to see the payments your Blue Cross Medicare Advantage plan is making on your behalf.
Think of it like a bank statement.
What is an Explanation of Benefits (EOB)?
Why is it important?
When do you get an Explanation of Benefits?
How to read your Explanation of Benefits
What to do if you something that doesn’t look right
What is an Explanation of Benefits?
Your Explanation of Benefits might look a little like an official document, but it’s nothing to worry about, it’s not a bill. Most of the time it’s telling you that your insurance plan has paid your providers on your behalf.
Let’s say you’re playing with your grandchildren and you twist your ankle. You go to urgent care to check it out. The urgent care doctor wraps it up and sends you off for some X-rays, and then you meet with your primary care provider a few days later. A couple of weeks go by and you may get statements from urgent care, the doctor who read your X-ray, and your primary care provider. You’ll want to hold onto these statements, to compare them against your Explanation of Benefits.
Providers may send you their own statement or they may not. If they do, it never hurts to compare it against your Explanation of Benefits to make sure everything is correct.
Your Explanation of Benefits tells you everything you need to
KNOW and how much you may OWE – but it still doesn’t make it a
The most important part of an Explanation of Benefits is the section named “Amount You May Owe.” Often, the Copay is the only section showing a dollar amount, and you may have already paid that amount at the doctor’s office or hospital. But every once in a while, you may owe for Co-insurance or something that’s not covered by your plan. If you see an amount there, you can expect to get a bill from your provider.
Blue Cross Medicare Advantage Explanation of Benefits example. Sections highlighted in this order: Amount you may owe, Copay, Co-Insurance, Non-Covered
See here in this example, under “Total Charges” of 260 dollars, this is for an urgent care visit. Then you look over here at this column and you see that the health plan and urgent care have negotiated 98 dollars and 62 cents for that visit, it notes the 5-dollar copay that was paid at check-in.
This section here is between Blue Cross Medicare Advantage and your provider — you don’t need to be concerned about this part.
Blue Cross Medicare Advantage Explanation of Benefits example. Sections highlighted in this order: Total Charges, Amount Paid, Copay, Reason Codes
The original billed amount, or “Total Charges,” is the standard rate for a given procedure, and some people without insurance have to pay that amount. The great thing about being a part of this plan is that they negotiate on your behalf — that is literally the “advantage” of having Blue Cross Medicare Advantage.
If you have a PPO plan, your Explanation of Benefits statement will have one additional section called “deductible.” Until you meet your deductible, you’re responsible for the amount listed here. But remember, this still isn’t the bill — you’ll receive that from your provider.
Blue Cross Medicare Advantage Explanation of Benefits example. Section highlighted: Deductible
One more section on your annual or quarterly explanation of Benefits is your Yearly Maximum Out-of-Pocket. Most of the time, most people don’t come close to reaching their annual limit, but it’s good to know there is a limit of what you may have to pay in a year.
And all the same principles apply with the Explanation of Benefits statements for prescription drugs. Once you’re familiar with this, this will make sense, too.
What if I see something that doesn’t look right?
Your Explanation of Benefits can also help you protect against fraud and identity theft. If you see anything on your Explanation of Benefits that doesn’t look familiar, like a procedure or a doctor visit you didn’t have, call the number on the back of your member ID card.
There’s nothing better than having a little peace of mind, and with your Explanation of Benefits, you have so much of the information you need to understand your health care.
Blue Cross Medicare Advantage (HMO) logo, Blue Cross Medicare Advantage (HMO-POS) logo, Blue Cross Medicare Advantage (PPO) logo.
Blue Cross Medicare Advantage HMO plan in New Mexico, HMO and HMO-POS plans in Illinois, and PPO plans in Illinois, Montana and New Mexico are provided by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC). Blue Cross Medicare Advantage PPO plans in Texas are provided by HCSC Insurance Services Company (HISC). Blue Cross Medicare Advantage HMO plans in Texas are provided by GHS Insurance Company (GHS). Blue Cross Medicare Advantage HMO plan in Oklahoma is provided by GHS Health Maintenance Organization, Inc. d/b/a BlueLincs HMO (BlueLincs). HCSC, HISC, GHS, and BlueLincs are Independent Licensees of the Blue Cross and Blue Shield Association. HCSC, HISC, GHS and BlueLincs are Medicare Advantage organizations with a Medicare contract. Enrollment in Blue Cross Medicare Advantage plans depends on contract renewal. Y0096_MAPDEOBVIDTMP19_C
Hello, I've responded to you on your private message. ~ Heather
Contrary to what this presentation states, the column headed "non-covered" does not seem to mean that the patient must pay this amount. At least I have never received a bill for these amounts. For a Medicare advantage plan, that appears to be the amount that is paid to the provider after the plan disallow amount is deducted. It would not make sense for that identical amount to be non-covered and yet paid. I have hundreds of EOBs with this situation. The reason codes (as kmuller17 comments) are all grouped together at the end, so that you don't know which code applies to which charge.
By the way, if you try to copy the EOB to send to a third party the column headings in gray completely disappear. This is not helpful!
Hello, Thank you for your feedback. If you have a claim denial that you'd like us to look into for you, please send us a private message and I can have someone give you a call about your situation. ~ Heather
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Last Updated 10012018Y0096_WEB_IL_CONNECT19_C