How to read an explanation of benefits (EOB)

Is an explanation of benefits a bill?

No. CMS says plainly that an explanation of benefits isn't a bill. It is a statement from your health plan showing what was charged and how the plan handled it.

Wait for the real bill from your provider, then compare the two. CMS says your bill should not be higher than the Patient Balance on the EOB, and if it is, talk to your provider.

What does each line on my EOB mean?

Every plan lays it out a little differently, but these are the parts the CMS guide walks through. Check your own EOB for the exact labels.

• Step 1: General information. This part shows a reference number called the claim number, plus who provided your care and when. Keep the claim number, because you will need it for any call or appeal.
• Step 2: Claim details. This lists the date of service and a short description of what was done, such as a medical visit, a lab test, or a screening. Check that it matches what actually happened.
• Step 3: Bill information. Provider Charges is what the provider billed. Allowed Charges is the amount the provider will be paid, which may be different. Paid by Insurer is what your plan will pay the provider.
• Step 4: What You Owe. Also called Patient Balance. This is what you owe after your plan has paid its share. If you already paid part of it, the EOB does not show that.
• Step 5: Remark codes. A remark code is a short note from your plan, usually 2 or 3 letters and numbers, that explains more about the costs, charges, and payments. The bottom of the EOB tells you what each code means.

What does denied mean on my EOB?

Denied means your plan decided not to pay for that service, in whole or in part. Look for a remark code on that line, then read what the bottom of the EOB says it means.

A denial is a decision, and decisions can be questioned. You are allowed to ask the plan to explain it and to ask it to look again through an appeal.

Why is the allowed amount lower than the charge?

CMS notes that the Allowed Charges, the amount your provider will be paid, may not be the same as the Provider Charges. Some EOBs label that gap as an adjustment.

The difference is not automatically something you owe. Look at What You Owe or Patient Balance, and talk to your provider if a bill is higher than that.

My claim was denied. What do I do next?

Take it one small step at a time. You have time, and you can ask for help. The deadlines below come from HealthCare.gov and apply to most private health plans, such as Marketplace and many job-based plans. Medicare, Medicaid, and some other plans have their own appeal steps and deadlines, so your denial letter is the final word on yours.

• Step 1: Keep everything. Save the EOB, any denial letter, and the bill. For each phone call, write down the day, time, and the name and title of the person you talked to.
• Step 2: Find the reason. Look for the remark code on the denied line and read what it says. Call the number on your plan card and ask them to explain it in plain words.
• Step 3: Ask for an internal appeal. HealthCare.gov says you must file within 180 days (6 months) of getting the denial notice. Fill out your plan's forms, or write a letter with your name, claim number, and health insurance ID number. Add anything that helps, such as a letter from your doctor. Send copies and keep the originals.
• Step 4: Know the next level. If the plan still says no, you may be able to ask for an outside review, called an external review. HealthCare.gov says to file a written request within 4 months of the notice, and your insurer is required by law to accept the outside reviewer's decision.

How long do I have to appeal, and how long will the plan take?

HealthCare.gov says you must file an internal appeal within 180 days (6 months) of receiving the denial notice. Rules differ by plan type, such as Medicare, Medicaid, or a job-based plan, and by state, so check your own letter for the exact date.

For a service you have not received yet, the plan has 30 days to finish the internal appeal. For a service you already received, it has 60 days. For an urgent case, the decision must come as fast as your condition requires, and no later than 4 business days.

Can I get help if I do not understand my EOB?

Yes. You can call the number on your health plan card. For questions about surprise medical bills under the No Surprises Act, CMS lists the No Surprises Help Desk at 1-800-985-3059.

You can also text a photo of your denial letter to (213) 606-6303. We read it and reply with where it breaks, free, no account, no form. We are not lawyers, and this is not legal or medical advice.

Your checklist

• Remember: the EOB is not a bill, so do not pay from it alone
• Find your claim number and write it down
• Check the date of service and description match what happened
• Compare Provider Charges, Allowed Charges, and Paid by Insurer
• Read the remark code for any denied line
• Match What You Owe to the bill you got, and call your provider if the bill is higher
• Check your denial letter for your plan's appeal deadline and mark it on a calendar

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• How to read an insurance denial letter
• How to ask your insurer for the denial reason in writing
• How to write an insurance appeal letter
• Internal appeal vs external review: what is the difference?
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.