After you submit an insurance claim, you’ll receive an Explanation of Benefits (EOB)—a document that tells you how your claim was processed. Understanding an EOB is critical for ensuring correct payments and identifying any issues. Let’s break down the key sections:
Claim Information
The EOB starts with basic details: the claim number, the patient’s name, and the date of service. It also lists the provider and the services rendered, including their respective procedure codes (CPT codes).
Amount Billed
This is the total amount you billed for the service(s) provided. It reflects the full charge before any insurance adjustments, payments, or patient responsibilities are applied.
Allowed Amount
Insurance companies don’t pay the full billed amount. The allowed amount is what the insurer considers fair reimbursement for the service, based on their contracted rates with the provider.
Insurance Payment
This section shows what the insurance company paid after any adjustments. It’s the actual amount they’ll cover, which could be different from the allowed amount depending on deductibles and other factors.
Adjustments
Often labeled as contractual adjustments or insurance adjustments, these are the amounts that you, as the provider, agree to write off. These are the difference between what you charged and what the insurance company allows.
Patient Responsibility
This section outlines what the patient owes. It may include:
- Copayments: The fixed amount the patient pays for the service.
- Coinsurance: A percentage of the allowed amount the patient is responsible for.
- Deductibles: If the patient hasn’t met their deductible, this amount will be applied here.
Denials or Reductions
If any part of the claim is denied or reduced, it will be explained here. The insurer will include denial codes or explanations such as lack of medical necessity, incorrect coding, or out-of-network services.
Balance Due
This final section summarizes any remaining amount that is the patient’s responsibility, either due to copayments, deductibles, or uncovered services.
At Clear Path Billing Solutions, we make mental health billing simple and efficient. From timely claims submission to handling denials, we take care of the details so you can focus on your clients. Let us streamline your billing process and improve your cash flow. Book your free consultation today!
