By Jennifer Jane, BSN, RN

When you go to a doctor visit, have a lab test, get admitted to the hospital, or receive any health care or treatment covered by your health insurance, the provider submits a claim to your health insurance company. 

After the claim is processed, your insurance plan sends you an Explanation of Benefits (EOB) — a statement from your health insurance company that breaks down the medical care and cost. It usually arrives by regular mail. You may also be able to see it on your member portal, if you have one.

The EOB tells you:

• What care was billed
• The claim number
• The date of service
• Who provided the service
• What your insurance plan covered
• What portion of the cost is your responsibility
  

An Explanation of Benefits is not a bill. It’s a summary of how your insurance processed the claim, not a request for payment. You’ll get a separate bill from your doctor or hospital if you owe money (1).

How are EOBs and medical bills different?

EOBs and medical bills differ by who sends them, their purpose, and whether the sender expects payment from you.

• Who sent it?
  
  • EOBs are sent by your health insurance plan.
  • Medical bills are sent by your doctor, lab, or hospital.
    
• What is the purpose?
  
  • EOBs explain what was charged to your insurance, what your plan paid, and how much you may be responsible for.
  • Medical bills tell you what care was provided, who to pay, how much you owe, and where to send the payment.
    
• Can you pay it?
  
  • EOBs are not a request for payment; they provide explanations only.
  • Medical bills need to be paid.
    

If the Explanation of Benefits and medical bill don’t match up, pick up the phone and call your insurance company and provider to ask questions — and get answers that make sense — before paying.

What’s Included on an EOB?

Different insurers format EOBs differently, but most will include:

• Patient and plan information
  Your name, member ID, the group, or employer
  
• Provider and date of service
  Who you saw (doctor, clinic, hospital, lab) and when
  
• Description of services
  A short description (office visit, lab test, ultrasound, etc.) and procedure codes
  
• Costs columns :
  
  • Provider charges – what the provider billed
    
  • Allowed amount – the discounted amount your plan has agreed to
    
  • Paid by plan – what your insurance paid
    
  • Not covered or patient responsibility – costs your plan didn’t cover that you owe
    
• What you may owe
  This may be broken into deductible, copay, and coinsurance
  
• Claim status
  Whether the claim was paid, partially paid, or denied (1)
  

Why do insurance companies send EOBs?

Research shows that many people struggle to understand EOBs. Insurance is confusing! A lack of understanding of how health insurance works is linked to delays in care and confusion about coverage (2).

Health insurance plans send EOBs to give you transparency into how your health plan benefits are being used and what you’re responsible for. They’re part of helping people understand their health care and make informed health-related decisions (3).

What should you do with an EOB?

Here’s a simple, practical list to follow when you receive an EOB:

1. Match the EOB to the visit:
   
   • Check the patient name, provider, and date of service to confirm  it’s your care.
     
2. Look at the service descriptions
   
   • Do they match with the care you received?
     
3. Compare the EOB to the bill
   
   • When the provider’s bill arrives, compare “what you owe” on the bill to the “patient responsibility” on the EOB.
     
   • If the bill is higher than the “patient responsibility” on the EOB, call the provider’s billing office and ask why.
     
4. Track your deductible and out-of-pocket max
   
   • EOBs often show how much of your yearly deductible and out-of-pocket maximum you’ve already met. If it doesn’t, you can call your insurance company and get a breakdown.
     
5. Watch for errors or fraud
   
   • If you see a visit, test, or procedure you never had, call your insurance company right away.
     
6. Use it for appeals
   
   • If your plan denies coverage, the EOB is part of the paper trail you’ll need to appeal a decision.
     

Keeping EOBs (in a folder, a downloaded PDF, or screenshots) provides you with a record you can use when you’re planning a budget, appealing a denial, or choosing plans during open enrollment.

How Lyvona can help you make sense of EOBs

Pregnancy and postpartum care generate a lot of EOBs: prenatal labs, ultrasounds, anesthesia, hospital charges, baby’s separate bills, and postpartum visits. Lyvona can help you make sense of all of them.  

On Lyvona.com, pregnant and new parents can:

• Upload bills and EOBs, ask questions, and see other moms’ costs.
  
• Use pregnancy-specific cost modeling tools to see what you can expect to pay for pregnancy and birth.
  
• Get support in communities moderated by health professionals, where you can ask questions about your EOBs and get judgment-free, clear answers.
  

Research shows that when people have clearer information and have a better understanding of their health insurance, they make more confident choices, seek out the care they need, and financial stress can be reduced (4).

Lyvona is supporting families with this goal in mind, specifically for pregnancy and new parenthood—where the EOB pile is extra tall.

Sources: 

1. https://www.cms.gov/medical-bill-rights/help/guides/explanation-of-benefits 
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC8973763/ 
3. https://www.cdc.gov/health-literacy/php/about/understanding.html 
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC12697310/