Always Review Your Explanation of Benefits (EOB) Statements


Article by Sarah Nash
Training Director, CU Insurance Solutions 

Do you understand those EOB (Explanation of Benefits) statements you get from your health insurance carrier?  My health insurance carrier is Anthem.  It’s a lot of information.  There’s the service date, service, reason code, doctor charges, your discounts, due to your doctor (maximum allowed), Anthem paid, and then there’s the column of what you owe.  Most people probably wish they had a secret decoder ring to help understand these statements!

Recently I received an EOB from my health insurance carrier.  I saw two visits, on two different dates, that were for exactly the same thing within the same medical facility (Mercy Northern Light).  One visit was zero cost to me, and one was $44.98.  I thought that was a bit strange, so I called the insurance company.  I spoke to a very helpful person who looked at both claims.  She determined that one was coded strictly preventive, and one was coded Z392 which is preventive but had a post-partum notation.  Huh?  The one and only child I have had was born in 1994, and I don’t think post-partum pertains at this point in time.  She told me to call Mercy Northern Light’s billing department.  I spoke to another very helpful person who determined that because I already paid the bill, she’d have to transfer me to the Central Business Office of Mercy Northern Light to request a code review.  I spoke to the helpful person there who sent my information in for a code review.  Typically, you will get your EOB prior to your bill.  This was not the case; I received the bill first.  Because they offer you a small discount to pay before the due date, I take advantage of this when I am able.

I have not heard back yet whether the code review was changed in my favor or not.  If it is not found to be in my favor, I do still have another option to try and get this remedied.  I can appeal the claim.  There are instructions on your EOB statement on how to file an appeal.

We often trust that these EOB statements are correct, and most of the time they are.  Humans make mistakes, so this is just a reminder to look them over and if you have questions ask your health insurance carrier.  Please also keep in mind that we are experiencing many examples of businesses being short-staffed.  Patience is a virtue.