EOB (Explanation of Benefits)

An Explanation of Benefits, or EOB, is a statement from your health insurance plan describing how a specific medical claim was processed. It comes from your insurer (not your doctor) and explains what the service was, what was billed, what the plan paid, and what you owe.

An EOB is not a bill. The actual bill comes from the doctor’s office, hospital, or pharmacy. But the EOB shows you exactly what your plan paid and why, so you can verify the bill matches.

What an EOB shows

A typical EOB includes:

• Provider name — Who provided the care
• Date of service — When the care happened
• Service description — What was done (CPT codes and plain language)
• Amount billed — What the provider charged
• Allowed amount (negotiated rate) — What the plan agreed to pay providers
• Amount paid by plan — What the insurer paid
• Your responsibility — Deductible, copay, or coinsurance you owe
• Reason codes — Why some charges were denied or adjusted
• Year-to-date totals — How much you have paid toward your deductible and out-of-pocket maximum

Why read your EOBs

EOBs are how you catch:

• Billing errors — Wrong codes, services you did not receive, duplicate charges
• Denied claims — Services the plan refused to pay, which you can appeal
• Network issues — Claims paid as out-of-network when you thought you were in-network
• Coverage gaps — Services you assumed were covered but were not
• Deductible progress — How close you are to meeting your deductible and out-of-pocket maximum

Always cross-reference your EOB with the bill from the provider. The amount you owe on the EOB should match what the provider is asking you to pay.

EOB vs. bill

EOB	Bill
From your insurer	From your provider
Explains what plan paid	Asks you to pay
Includes negotiated rate	Includes what you owe after insurance
Not a request for payment	Is a request for payment

If the bill is higher than the EOB says you owe, contact the provider’s billing office immediately. Sometimes providers bill before the insurer has processed the claim, and you should wait for the EOB before paying.

How to get EOBs

Most plans send EOBs:

• By mail (paper EOB) — Older default, slower
• By email or text alert — Pointing you to the member portal
• Through the member portal — Most carriers now have online portals where you can see all EOBs

You can sign up for paperless EOBs through your insurer’s member portal to reduce mail.

When to appeal

If an EOB shows a claim was denied or paid less than expected:

1. Read the reason code on the EOB.
2. Contact the insurer to clarify.
3. If you disagree, file an internal appeal — most insurers have 30-180 days to decide.
4. If the internal appeal fails, request an external (independent) review.
5. File a complaint with your state insurance department if needed.

Most appeals must be filed within 180 days of receiving the denial.

Year-end EOB review

At the end of each year, review your EOBs against your deductible and out-of-pocket maximum. Insurers occasionally miscount — for example, failing to credit a copay toward the OOP max. Catch errors before the year closes.

Related terms

• Deductible
• Copay
• Coinsurance
• Out-of-Pocket Maximum

Get help reading your EOB — a licensed agent can help interpret denials and identify billing errors.