Understanding health insurance reimbursements is complicated if you are not familiar with health care industry billing terminology. With each medical, dental or behavioral health care claim submitted for payment, your insurer will generate an Explanation of Benefits document. The EOB is not a bill but explains services billed and their reimbursement details. The EOB should help you understand health insurance reimbursements, but if they do not, your health plan, doctor's office or other community resources will assist you.
Instructions
1. Review the Explanation of Benefits document sent to you in response to a claim filing. Each EOB contains the name of the doctor, facility or hospital providing service, the date of service, name of the service, doctor's charges, amount paid and amount owed. EOBs also contain an explanation of denial or reduced payment for services. Visit your health plan's website to view a sample EOB and an explanation of each item on the document.
2. Call your health insurance plan and ask they further explain the reimbursements. The EOB will contain a phone number where you can call to ask questions and obtain clarification.
3. Consult your health plan's summary plan description. This document contains information about services covered and excluded. Your benefits administrator must provide you with a copy of the summary plan description. Ask your benefits administrator or human resources department for a copy if you do not have one. You may also have other health plan communications listing benefit coverages, deductibles and co-pays.
4. Ask a billing representative at your doctor's office or the hospital to help explain the claims reimbursement to you. It is likely the doctor submitted the original claim and the billing staff could share their knowledge with you about charges and payments.
5. Contact your state's insurance department if you cannot get help from your health plan or through the health plan's materials. Each state employs representatives to help or redirect consumers with questions regarding health insurance.
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