Often, medical billing and coding can be hard to decipher. As a result, it’s not always obvious what you need to pay and what your insurance covers. Therefore, we recommend you wait to pay your medical bill until you receive your Explanation of Benefits (EOB). This document provides a breakdown of how much your insurance plan covers and how much you must pay out of your pocket.
If you’re interested in finding out how to read your medical bill and your EOB, keep reading to find out more. At Health Plans of NC, our local North Carolina health insurance agents are here to help with all your health insurance questions and ensure you get the right plan for your health needs.
If you’ve got insurance, you’ll receive an EOB after accessing a medical service, which shows what your insurance covers and can help you identify any issues, such as duplicate charges. If you don’t have insurance, you’ll need to pay for any medical services directly with your medical provider.
After receiving treatment or care, the medical service sends their bill to your insurance company. Your insurance company then determines how much your plan covers and sends you an EOB for your records. Your EOB clearly states ‘this is not a bill’, showing you what your insurance covers. After your insurance provider pays their share, your medical service will bill you for any outstanding amounts. You can usually also access your EOB on your insurance provider’s website.
Your EOB shows you the details of the total cost of your medical expenses, what your insurance provider will cover and what you have to pay out of pocket. There are standard terms on most EOBs regardless of your insurance provider, including:
Patient account number: this is your insurance ID, otherwise known as your health plan member number. You’ll usually find this on the back of your health insurance card and need this if contacting your insurance provider.
Claim number: this is your unique case number for the specific medical service you received.
Service code: relates to the specific clinic, hospital, or medical provider where you received care. Each visit, procedure, or medication you receive may also have a unique code.
Not covered: this refers to the amount not covered by your insurance provider and that you will need to pay for when you receive your final bill.
Reason code: if your insurance provider doesn’t cover specific procedures, they’ll list a reason code for why it’s not included.
Covered: this section shows the amount you’re covered for within your insurance plan. You’ll also typically see a deductible and copayment section highlighting how the bill is adjusted with your plan benefits.
Patient responsibility: this amount is the outstanding amount you’re responsible for paying to the medical provider and should match up to your final medical bill from the provider.
When it comes to medical billing, there are a few key terms to look out for, including:
Account number: this is your unique identification number with the service provider, and it’s usually needed when paying your bill.
Service date: these are the dates you received care. Check the dates are correct and contact your health care provider if you notice any issues.
Charges: refers to the total amount of your health care costs before your insurance provider has paid for any expenses. This figure is not what you owe.
Adjustment: refers to charges your healthcare provider has agreed not to charge you. Your insurance provider may have adjusted this amount.
Patient payments: this is the amount you owe and are required to pay.
Balance/Amount due: if you’ve already paid an out-of-pocket cost or copay when you received treatment, this amount may differ from your patient payment to reflect the outstanding amount.
If, after receiving your medical bill, you notice a discrepancy between the two amounts listed on your EOB and your final account, it may be a billing error. However, it could also be an issue of timing. For example, if your doctor’s office sends you their final bill before your insurance provider has paid their share.
Ensure you’ve received your EOB before paying your medical bill so that you can check. Your EOB is a critical document to help you work out what you owe so you don’t end up overpaying for any services. If you think there’s an issue, it’s a good idea to:
Request an itemized bill: contact your healthcare provider and ask for a fully itemized bill so you can see what exactly you’ve been charged. You can cross reference this to your EOB to help identify the error. If you’re unsure, call the provider to ask for their assistance.
Contact your insurance provider: if you’ve got questions relating to your EOB, or if you’ve been denied coverage for a specific treatment, you can get in touch with your provider to appeal the decision or ask for further assistance.
Here are some other things to consider when dealing with EOBs and medical bills:
Sometimes, health providers send you a bill immediately after receiving treatment but before your insurance provider has processed your claim. If you receive a bill before your insurance provider has paid anything, it can make it look like you owe more than you do, so it’s wise to wait to receive your EOB before paying any medical bills.
If you’re getting treatment for an ongoing condition, you might receive more than one medical bill over weeks or even months. It’s a good idea to hold off paying the first bill you receive to ensure that your insurance provider has paid their share before determining what you owe.
If you’re confused about your EOB or medical bill, your insurance provider is there to help. Remember to have your member ID number on hand.
You can also contact an independent health insurance agent NC to ask questions about your coverage, like our North Carolina-based agents. If you’re considering changing plans or purchasing insurance, they can do the research for you and help find the best insurance plan for you and your family.
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