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📋 EOB Decoder

Understand every section of your Explanation of Benefits — click each section to learn more

💡 What is an EOB? An Explanation of Benefits (EOB) is a statement from your insurance company showing what was billed, what they paid, and what you owe. It's not a bill — but it helps you understand your upcoming bill.

1 Patient & Provider Information

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This section identifies who received care and where.

  • Patient Name — The person who received the medical service
  • Member ID — Your insurance identification number
  • Provider Name — The doctor, hospital, or facility that provided care
  • Claim Number — Unique ID for this specific claim
  • Date of Service — When the care was provided
✅ Check: Make sure the dates match when you actually received care. Incorrect dates could indicate billing errors or fraud.

2 Service Details & Charges

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The breakdown of what was billed for each service.

  • CPT/HCPCS Code — Standard procedure code identifying the service
  • Description — Plain-language description of the service
  • Billed Amount — What the provider charged (often inflated "chargemaster" rates)
  • Units — How many times the service was performed
Example

CPT 99213 — Office visit, established patient, moderate complexity
Billed: $250 | Units: 1

💡 Tip: The billed amount is almost never what gets paid. It's the provider's "sticker price" before insurance negotiations.

3 Allowed Amount (Negotiated Rate)

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This is the most important number on your EOB.

  • Allowed Amount — The maximum your insurance will pay for this service, based on their negotiated rate with the provider
  • Network Discount — The difference between billed and allowed (your savings from using in-network providers)
Example

Billed: $250 → Allowed: $150
You saved $100 through your insurance's negotiated rate!

🔍 Use our Provider Compare tool to see negotiated rates across hospitals before you receive care.

4 Insurance Payment

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What your insurance company actually paid the provider.

  • Plan Paid — Amount your insurance paid to the provider
  • Adjustment/Write-off — Amount the provider agreed to write off per their contract

5 Your Responsibility

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The amount you're responsible for paying. This breaks down into several components:

  • Deductible — Amount applied to your annual deductible (you pay 100% until met)
  • Copay — Fixed amount you pay per visit or service
  • Coinsurance — Your percentage share after deductible is met (e.g., 20%)
  • Not Covered — Services your plan doesn't cover at all
  • Patient Responsibility — Total you owe (deductible + copay + coinsurance + not covered)
Example Breakdown

Allowed Amount: $150
Applied to Deductible: $150 (deductible not yet met)
Copay: $0 | Coinsurance: $0
You Owe: $150

⚠️ Important: Wait for the actual bill from the provider before paying. The EOB tells you what to expect, but the bill is the payment request.

6 Deductible & OOP Tracking

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Many EOBs show your year-to-date progress toward key limits.

  • Deductible Met — How much of your annual deductible you've used
  • Out-of-Pocket Met — Progress toward your annual OOP maximum
  • Remaining — How much more you could owe before hitting your limit
📈 Use our Savings Dashboard to track your deductible and OOP progress throughout the year.

7 Denial & Appeal Information

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If any part of your claim was denied, this section explains why and your options.

  • Denial Reason Code — A code explaining why a service wasn't covered
  • Appeal Rights — Your right to challenge the denial
  • Appeal Deadline — Typically 180 days from the denial date
⚡ Don't ignore denials! About 50% of insurance appeals are successful. Always appeal if you believe the service should be covered.

Need help reviewing a specific bill?

Use our interactive Bill Review Checklist to catch errors and find savings opportunities.

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