When you get health care, the doctor, hospital or other provider asks us to pay for the service they provided by submitting a claim. After we process the claim, you get a claim statement or an explanation of benefits (EOB).
It’s the statement that says, “This Is Not a Bill.”
If it’s not a bill, what is it?
It’s a document that provides information about what fees your provider charged, what was covered by your health plan, how much your health plan paid and how much you may still owe.
Your EOB is designed to be easy to read and understand. It is divided into three sections.
1. Subscriber Information and Claims Table
The top part of the EOB includes your name, address, ID number, and group name and number. It also includes a table that shows the amount your provider billed for the claims included in the EOB, any applied discounts and the amount you may owe the provider.
2. Service Detail for Each Claim
Section 2 itemizes the services that were billed. It lists all the different procedures, tests, drugs or equipment charges individually. The detail for each claim describes each service you received, the facility or doctor, the dates and the charges. It shows discounts and other reductions your Blue Cross and Blue Shield of New Mexico (BCBSNM) benefits plan provides for you. And you can see any costs that may not be covered.
3. Cost Summary
The last section includes two key details.
Plan Provisions includes the charges for what services were “allowed” – meaning what your health plan covered. If the provider billed BCBSNM for a service not covered by your plan, it won’t be included in this section. Also included in this section is how much the deductible, copay and coinsurance will pay toward the claim.
Your Responsibility shows what you may pay out of pocket, including the deductible, copay and coinsurance, and anything not covered by your plan. It is all added together to show a total amount that you may owe the provider.
Since a claim statement or EOB isn’t a bill, the amount we list as “what you may have to pay your provider” is for your information only. If you owe the doctor, hospital or other provider an amount you haven’t already paid, they’ll send you an invoice. Comparing the invoice to your EOB is a good way to make sure you’re getting billed correctly.
If you have a claim that isn’t approved, you can look at the EOB to find out why. The EOB will list a code that identifies the type of denial and provides a key that explains what each code means.
Included in with the EOB is information about how to appeal if you believe a claim has been denied in error. You can follow the simple instructions to appeal the decision.
Save your EOBs.
Remember to keep your claim statements or EOBs in case questions come up later about your claim or your bill. Keep your EOBs in a safe place with your other important personal documents, such as your medical records. If you’re signed up for Blue Access for MembersSM (BAMSM), we store your EOBs there for 18 months.