Choate House on the Pace Pleasantville campus

Explanation of Benefits (EOB)

Understanding Your Explanation of Benefits (EOB)

Your Explanation of Benefits statement (EOB) provided by Aetna is not a bill, but instead a wealth of information for you to review and determine if there are any billing discrepancies, and what you estimated payment responsibilities, if any, will be once the bill is processed . Aetna is trying to provide the hard facts and figures to you so that you can make the best educated decision possible based on what is being reported. Many people are unsure of how to read an Explanation of Benefits. In order to better understand your explanation of benefits form, you need to know exactly what the EOB is, the different parts of the EOB and finally, what the important parts can tell you.

EOBs are mailed to participants but can also be retrieved electronically.

What Is the EOB?

The information applied to your EOB helps you understand how your insurance benefits were applied to each and every claim reported to Aetna. The EOB includes the service date, provider’s name and amount covered, along with other pertinent information. EOBs also help you keep track of how much you have been credited towards a certain deductible, so you do not have to keep track of the figures on your own. Insurance companies recommend that you hold on to your EOB for at least two years, but no more than three years to verify consistency or develop a pattern for your health care.

Parts of the EOB

The EOB may seem like it is filled with a bunch of information, but much of the writing is for basic identification purposes, such as the patient’s name, account number and contact information for your insurance provider. Also included on the EOB is the amount charged by the healthcare provider, the amount negotiated by your insurance plan and the amount paid by Aetna. At this point, the rest of the information on the EOB pertains to you and what you will owe.

Next, you will probably notice your deductible amount, which is the amount that you will pay out of pocket before the insurance will make claims for you, any co-payment or co-insurance you might have and the amount not covered by your insurance plan. The amount not covered will generally have a reason for not being covered, either the specific service is not covered under your insurance plan, out-of-network service, or any service that required a pre-qualification before the service could be rendered. Finally, you should see a section that will describe any payments by other insurance policies you have on your account and at the end, what you as the patient are responsible for paying.

Reading the EOB

When it comes to reading your EOB, there comes a point where you look at the information given and try to decide if there is a better way to go about getting health coverage. For example, if you look at the amount paid by the insurance company and it is $0.00 and you owe the full amount to the healthcare provider - it is a good idea to check the reason code. You might just learn that the doctor you have chosen to see is out of network and not covered by your insurance plan. At this point, it would be wise to call Aetna and see which providers in your area are covered under the plan. This will save you time and money in the long run.

Your EOB is not difficult to read, understand, and interpret. It does take time and effort to think about what everything means and how it applies to your health care, but with practice, it is easy to find trends and look for better ways to maximize your health coverage.

If you ever have questions or suspect any errors in your EOB, don’t hesitate to ask for assistance. Consider calling both Aetna and your healthcare provider to verify that the explanations are in sync. Always take notes, and if possible, retrieve a case number for these calls in case you need to dispute a bill. Communication with all parties is important for your understanding, and if you find a mistake, it is usually correctable.