Explanation of benefits (EOB)

An explanation of benefits (EOB) is a statement you receive from your insurance company after you get care. It's not a bill, but it breaks down the cost of the services you received, how much your health plan will pay, and how much you may owe.

In the past, EOBs included lots of numbers and codes with very little explanation of what they mean. EOBs looked so much like bills that insurance companies started printing "This is not a bill" on the first page. We've radically simplified the Oscar EOB (opens in new tab), but if you're not used to reading these statements, you might have a few questions. We've answered some of the most common questions below.

What is an EOB and why are you sending it to me?

OK, here's how it works. When you go to the doctor, the doctor's office will send a claim (opens in new tab) to your insurance company explaining the services you received and how much they cost. Then your insurance company processes the claim and pays a certain amount of what your doctor billed based on its negotiated rates (opens in new tab) and the benefits included in your insurance plan. Your insurer then sends you an EOB with these details, including how much of the final total you owe. So the EOB is how you'll see your health plan in action.

If you're responsible for all or part of the cost of the services you received, you owe it to the doctor's office, hospital, or lab that provided the service – not your insurance company. That's why an EOB isn't technically a bill. In some cases, for example if you owed a $40 copay at the doctor's office, they may have collected that amount up front. In other cases, they may send you a separate bill.

What’s on an EOB?

Your EOB will include information about:

• The services you received: Your health care provider will list the procedures you received and assign a billing code to each. For example, an “Office Visit” might be a routine checkup, while “Diagnostic Work” might be a blood test your doctor ordered. You can learn more about what the code means in the notes section.
• Date covered: The date (or date range) when you received the health care service.
• Amount billed: This is the rate your doctor charges for the service. Because you have health insurance, the rate you pay is negotiated by your insurance company. So the amount billed is not how much your health care provider will actually be paid.
• Plan discount: This shows how much you saved with your insurer’s pre-negotiated rate. Oscar’s negotiated rates are ten to 60 percent lower than the provider's full price, depending on the service.
• Your plan pays: This is the amount your insurer will pay your health care provider based on the negotiated rate and the terms of your plan.
• Estimated member responsibility/You owe: This is the itemized total you personally owe the provider. The amount your owe depends on the way your health plan shares costs:
• Deductible: If your plan has a deductible (opens in new tab) and your health care spending hasn't reached this amount yet, your plan would pay nothing and you may owe the full negotiated rate for the service.
• Copays & Coinsurance: If you have met your deductible or don't have a deductible, your plan may include copays or coinsurance where you pay a fixed amount or percentage of the bill. In this case, the portion you owe will be listed on the EOB. Keep in mind that you may have already paid it during your visit.
• Non-covered services: Some services, like cosmetic surgery or procedures from an out-of-network (opens in new tab) provider, are not covered by your insurer. If there are any non-covered charges, they will be explained in the notes section and you would be responsible for the cost of these services. These payments would not count toward your plan's deductible or out-of-pocket max.
• Notes: These usually include a description of the service codes along with any other explanations necessary, including services not covered by your plan.

When do I pay?

When you get an EOB, you don’t pay anything immediately. If you only owed a copay and paid at the time of service, you may owe nothing. If you do owe a balance, you should receive a separate bill directly from your provider. Check over your EOB carefully to be sure that you are being billed for the correct services.

How do I dispute a claim?

There's nothing worse than being surprised by the information in your EOB. If you're concerned about something you see in your EOB, call your health insurance company for help. In some cases, if the claim was not submitted properly, or there was a billing error, they can work with you and your provider to resubmit the claim.