How to read your explanation of benefits
What is an EOB?
An explanation of benefits (EOB) is a list of claims Blue Cross NC received from your health care provider. It’s not a bill. It’s a document your insurance company sends you after a medical claim has been processed.
It breaks down the costs for claims received by your provider, how much your insurance plan covered, and how much you may still owe.
What you'll find in your EOB
You'll find how much your provider charged. This is the billed amount.
The amount we paid, or covered amount, is the portion of the services covered by your insurance plan.
The allowed amount is the maximum amount your insurance will pay for a service and is found in Claim Details in the Allowed Amount column.
You’ll learn how much of your care was covered by your insurance.
The paid amount is the amount paid by your insurance company to the provider.
Reason codes may be included when changes are made to the cost of your services due to contractual adjustments or negotiated rates.
Your EOB is not a bill, but you may still have a balance for a claim we received.
If you do owe on a service, your EOB will show how much, but you’ll be billed by your provider – not your insurance company.
Your EOB will break down how much you may owe for each individual service.
Identifying your documents
At the top of the EOB, you’ll find the highlights, including your name, subscriber ID, name of your health plan, and your EOB statement date.
You’ll also find a summary of your claims, including the total amount your provider billed, how much Blue Cross NC paid, and how much you may owe.
The total for how much you owe may not reflect recent payments you made.
The Claim Details section breaks down your summary. It includes the provider's name, your claim number, payment details, and the date you received care.
You’ll also find the total amount paid per service under We Paid, as well as the allowed amount for each service. If your claim includes a reason code, you’ll find it here.
The Claim Details also shows the amount remaining you may owe for a service.
If a denied claim is listed on your EOB, you can file an appeal. The appeals page explains the steps you'll need to take to appeal a claim.
You can find the appeals forms you need on our Member Forms page. When you file an appeal, your provider will need to send extra information to your insurance company showing that the service, treatment, or medication is medically necessary for you.
Check for errors
It's important to make sure the information on your EOB, such as claim details and services you received, is correct.
Check the following information listed under the summary and Claim Details sections of your EOB carefully for accuracy:
- Your personal details, such as your name and subscriber ID
- Billed amounts from your provider
- Service dates your provider listed in your claim match up to the dates you were seen for care
- Payments made from your insurance company to your provider
- No additional services were added to your claim that you didn't receive from your provider
You can find your health plan details in your Benefit Booklet on the member portal.
