Explanation of Benefits

An Explanation of Your Explanation of Benefits (EOB)

What is a health insurance Explanation of Benefits (EOB)?

An Explanation of Benefits (EOB) Statement is a notification provided to members when a health
care benefits claim is processed by Blue Cross and Blue Shield of Texas (BCBSTX). The EOB outlines the expenses submitted by the provider and shows how the claim was processed. In most cases, an EOB will be mailed to you after a claim has been finalized. If you signed up for paperless statements, you will instead get an email notice when your EOB is ready for viewing through your Blue Access for MembersSM (BAM) account .

When you receive your EOB, don’t just glance at it and toss it aside. It’s an important record of claims for medical services and benefit coverage, so you should always carefully check your EOB. Double check that the services you received match the services you’ve been billed for. If something doesn’t quite look right, call us at the number on the back of your Member ID card or ask your doctor about it. Keep your EOBs on file for future reference — just in case questions come up later about a claim or your bill. If you’re registered for BAM, we store your EOBs there for 18 months.

The EOB has four sections:

  • Claim Information includes the member and patient name, the member’s group and ID numbers and the claim number. To learn more on how to read your claim, click on the Health Care School widget located in BAM  and watch the “Reading your Claim Statement” video.
  • Summary highlights the financial information – amount billed, total benefits approved and the amount you may owe the provider.
  • Service Information identifies the health care facility or physician, dates of service as well as charges.
  • Coverage Information shows what was paid to whom, what discounts and deductions apply, and what part of the total expense was not covered.

The EOB may include additional information:

  • Amounts Not Covered will show provider discounts, or what benefit limitations or exclusions apply.
  • Out-of-Pocket Expenses will show an amount when a claim applies toward your deductible or counts toward your out-of-pocket expenses.
  • Appeals explain your rights regarding review of claim denials.
  • Fraud Hotline is a toll-free number to call if you think you are being charged for services you did not receive or if you suspect any fraudulent activity.

Below is a sample EOB with all the sections labeled. Keep in mind, every plan is different and the charges on your EOB are according to your plan’s coverage and the services you received.

If you’re not familiar with EOBs, you might still have questions. If so feel free to give us a call at 888.511.2489.

 

An example of and EOB with detailed description of each field…

Texas EOB Screen Shot 2015-05-11 at 11.26.08 AM