Explanation of Benefits (EOB) or Remittance Advice - In many cases these terms are used interchangeably; however, they are different. The Explanation of Benefits is sent to a patient that explains how the insurance processed their services rendered, what was paid or not paid to the provider, and what the patient owes. The Remittance Advice provides information to the healthcare facility or office on whether they need to appeal the claims processing or accept the processing as received.

Review the Explanation of Benefits (EOB) from Cigna and CMS

https://www.cigna.com/assets/docs/explanation-of-benefits/explanationOfBenefits832700.pdf(Links to an external site.)

https://www.bcbsm.com/content/dam/microsites/eob-guide/eob-guide.pdf(Links to an external site.)

1. Which parts of the Explanation of Benefits appear difficult for you to understand and explain why?
2. How would you explain to the patient what was paid or not paid by the insurance provider?
3. What differences do you see between the two EOBs presented?
4. Pick one of the EOBs presented
   • Explain why there is a difference between the amount billed, allowed, and paid.
   • Additionally, what is the patient's portion and explain whether the patient's portion was a deductible, copayment, or coinsurance?