An Explanation of Benefits, or EOB, is a statement from your health plan showing how an addiction-treatment claim was processed. It typically lists the provider, dates of service, billed charges, the insurer’s allowed amount, what the plan paid, and what the patient may owe. An EOB is not itself a bill.
What information appears on an EOB?
CMS explains that EOBs commonly include the patient and plan information, provider, claim number, dates of service, service descriptions, provider charges, allowed charges, insurer payment, and patient balance.
What is the allowed amount?
The allowed amount is the amount the health plan recognizes for a covered service. It may be lower than the provider’s billed charge and can affect coinsurance and patient responsibility.
Why might an addiction-treatment EOB show a denial?
A claim can be denied because of authorization requirements, network status, medical necessity, exclusions, coding issues, missing information, or other plan rules. The EOB or related denial notice should provide a reason or remark code.
Is the EOB the same as the provider’s bill?
No. The EOB comes from the insurer. The provider sends the actual bill. Compare the two and contact both parties if the provider bill exceeds the amount the EOB says you owe or if services appear incorrect.
How is an EOB different from benefits verification?
Benefits verification happens before claims are processed and estimates how the plan may apply. An EOB reflects how a specific submitted claim was actually adjudicated. See Trinity’s guide on why final rehab bills can differ from benefits verification.
What should I do if I disagree with the EOB?
Ask the insurer to explain the claim, request correction of any errors, and review appeal rights if coverage was denied. Keep copies of the EOB, bills, denial notices, and relevant plan documents.
Trinity Behavioral Health can verify private PPO benefits, but benefits verification does not guarantee final claim payment.
Frequently asked questions
Do I pay the EOB?
No. Pay the provider’s valid bill, not the EOB itself.
Can an EOB arrive before the bill?
Yes. CMS notes that an EOB often arrives before a provider bill.
What if the EOB says I owe $0?
Compare any later provider bill carefully and ask questions if it does not match the plan’s claim determination.
Sources
This article provides general insurance information, not legal or financial advice.