Tuesday, 14 January 2014

Understanding EOB - Explanation of Benefits

Amount Billed

This represents the cost of the services and the amount Charged by the provider to the insurance company. i.e Amount Billed By the Provider for the service(Treatment) rendered. In Some Payer EOB, this also labelled as "Actual Amount Billed" or "Provider Charge" or "Amount Billed" or "Amount Charged" or "Charge" or "Charged Amount" or "Total Charges" or “Billed” .

Allowed Amount

Allowed amount reflects how much the Payer has decided to pay for the procedure or visit. Sometimes Payer will use the term “usual and customary charges” or another term in place of “allowed amount.”

Providers who have agreed to accept the insurance company’s allowed amount for visits and procedures are considered “in-network” providers. If you visited an in-network provider, you will not be charged the difference if the provider’s charge is higher than the allowed amount.

Some out-of-network providers do not agree to accept the insurance company’s allowed amount as full payment for a visit or service. If this is the case, you will likely be required to pay the difference between the doctor’s fee for a service and the allowed amount the insurance will pay. In some cases, the insurer does not provide any coverage for out-of-network care and you may find yourself paying the full charged price of the care you received.

Allowed Amount is usually determined by geographic location of provider.

In Some Payer EOB, this also labelled as "Amount Allowed" or "Payment Amount" or "Allowable Amount" or "Remaining Covered Charges" or "Contracted Amount" or " or “Allowed” .

Date of Service

The the actual date that the medical service/procedure was performed by the  Provider. This is NOT the date it was billed or processed.

In Some Payer EOB, it is also labelled as "DOS" or "Service Date"

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