Understanding Your Explanation of Benefits
Your explanation of benefits (EOB) shows your medical claims and payments made by your health benefit plan. You’ll receive an EOB after you see your doctor or have a test done.
This guide will help you understand your EOB and all the information on it. Each numbered definition below corresponds to one of the numbers on the sample EOB on the following pages.
Sample Explanation of Benefits
The items appearing on the explanation of benefits (EOB) sample are for reference only. This sample shows claims and benefits for a family of five. Each family member’s claims are shown separately.
Number assigned to your employer
Date the EOB was issued
Name of person who received care
Description of the visit (e.g., physician visit)
Identifies the claim in our system
The date you received care
Services that have been billed to your health benefit plan
The amount that has been reduced from the provider
Negotiated or ineligible amounts that are not your responsibility
A payment made by another health plan due to coordination of benefits
Amount of submitted charges not covered by the plan
A predetermined charge that the provider can collect from you at the time of service
The amount of the covered charge that you are responsible for paying before your health plan starts sharing costs
A percentage of the covered expenses you are responsible for paying
Total amount your plan will pay for the submitted charge(s)
Percentage of the covered expense paid by your plan, after any applicable deductible
Used to explain why a portion of submitted charges is not covered by the plan. A number, or reason code, shown on the EOB corresponds with an explanation. (See page 2 of sample.)
Account number assigned by the facility or provider
Name of facility or provider
Date the claim was released and sent to processing
The total you are responsible for paying
Dollars applied toward the employee and covered dependents
Benefit payments made during this year
Depending on how the claim was paid, these items may appear differently. The claim will be paid with in-network or out-of-network rates. These items will include payments toward your deductible, out-of-pocket costs, and lifetime medical maximum allowance.
Questions about your EOB? Contact Wellstar Health Plan at the number on your ID card.
R006-178_WS-11-23