How to Decode Medical Insurance Claims

A medical insurance claim is called an explanation of benefits (EOB). When you have services from a healthcare provider, the health insurance carrier will provide an EOB to the member about how the services were processed in their system and why it was paid or not paid a particular way.

Things You'll Need

• Medical insurance claim / explanation of benefits
• Health insurance benefits
• Phone

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Instructions

Analyze the Medical Insurance Claim

• 1

  Learn the layout of an EOB. The fields on an EOB form are patient, claim ID, description of services, amount charged, other insurance paid, deductible, co-pay, co-insurance, other amounts not covered, amount paid and reason code. The claim ID is the claim number given to your medical service when it is received by the health insurance carrier. The reason code is the reason the claim/service was paid or not paid. Once you understand the fields on the claim or explanation of benefits, you can then decode the medical insurance claim.

• 2

  Identify the patient, date of service, physician or hospital that provided the services. Determine if you or another member of your family received services from that provider on that particular day.

• 3

  Contact the provider of care's billing office if something is incorrect. This is most likely not the physician's office directly. Locate the phone number on a bill that was sent to you from them or call the physician's office and request the billing office's number. When you call the billing office, document the name of the person you spoke to, date you called and get confirmation on when they will follow up with you about the error. This could be a medical bill showing zero due or the corrected information.

• 4

  Look at the EOB. Determine whether or not the claim was denied or paid by the insurance carrier. Simply check the difference between the charged, allowed amount, deductible, copay, coinsurance and the total amount payable. If the total payable amount equals zero, then the claim wasn't paid. Take a look at the reason codes. What are the reasons the claim was denied. You can find out what the symbols mean by looking at the bottom or the back of the EOB.

  The non-covered amount field tells you what the insurance carrier did not pay. If you went to a participating provider, then the non-covered amount should not be billed to you. Unless, you had a discussion with the provider ahead of time and both of you knew the insurance carrier was not going to pay for this particular service. You may be responsible for the amounts.