How to Read Your Explanation of Benefits (EOB)

What Is an EOB?

An EOB is NOT a bill. It's a summary of how your insurer processed a claim from your provider. It shows what was charged, what the insurer paid, and what you owe.

Key Sections of an EOB

Provider Charges

The total amount your provider billed for services rendered. This is the "list price."

Allowed Amount

The negotiated rate your insurer agreed to pay. In-network providers accept this as full payment.

Insurance Paid

What your insurer actually paid toward the allowed amount.

Your Responsibility

What you owe, broken down into:

• Deductible: Amount applied to your annual deductible
• Copay: Fixed amount per visit
• Coinsurance: Your percentage of costs after deductible
• Not covered: Amounts not covered by your plan

Denial Codes

If a service was denied, the EOB will include a reason code. Look up these codes in the chart below:

• CO-4: Procedure modifier inconsistent
• CO-97: Benefit maximum reached
• PR-204: Service/equipment not ordered by referring provider
• CO-50: Not medically necessary

What to Do With Your EOB

1. Compare with your provider bill — they should match
2. Check for errors — wrong dates, codes, or patient information
3. Review denial reasons — determine if an appeal is warranted
4. Keep all EOBs — they're your record of what was billed and paid