Explanation of benefits (EOB)

An EOB is the plan’s account of a claim, written for the member. It lists the provider, the dates of service, each service billed, the amount charged, the amount the plan allowed under its contract or fee schedule, the amount the plan paid, any amount the provider has to write off, and the part that falls to the patient as deductible, coinsurance or copay. It usually carries the plan’s own remark text explaining a denial or a reduction, and it states that it is not a bill. A paper remittance sent to the provider is often laid out the same way and is still called an EOB in many offices, though the electronic version is the ERA.

EOBs matter on the patient side of billing. The statement your practice sends should match the patient responsibility on the EOB, and when it does not, the patient notices before anyone else does. An EOB is also the fastest way to answer a patient’s question about why a visit cost what it did, and it is the document a secondary payer may ask for when it needs the primary payer’s determination to process a secondary claim.

The mistake is posting from the EOB without the codes. Patient-facing EOBs translate claim adjustment reason codes into plain language and sometimes leave out the group code, so a biller posting from one can book a denial as patient responsibility or a contractual adjustment as a denial. Post from the ERA or the provider remittance, and use the EOB to reconcile the patient side.