What is an Explanation of Benefits?
Let’s start with the fact that it is not a bill. An Explanation of Benefits (EOB) is a document you will receive from your insurance company explaining your recent visit at the dentist and how the insurance claim was processed. You may receive this document either electronically or in the mail after your visit.
What will an EOB Tell You?
An EOB is full of information and a great way to ensure you know what was done at your appointment. This document includes information such as:
- Description and date of treatment performed
- Dentist fees charged
- If the dentist is listed as In Network or Out of Network: If the provider is listed as In Network the EOB will list the negotiated discounts that may be applied to each procedure
- How much will be paid by insurance
- Amount the patient is responsible for, the co-pay
- The amount applied toward deductible, if any
- Amount of annual maximum benefit
After receiving an EOB, you will know the amount that you will owe your dentist. This portion of your EOB will take deductibles, co-payments, and co-pays into account to show the amount you should be paying as your co-pay. Normally an estimate is made when the treatment is planned and a co-pay is made at the time of service. For example, if you had a simple procedure performed with charges of $200 and your insurance plan covers 80/20% coinsurance benefits, then the EOB might indicate the plan made a payment of $160 and your responsibility will be $40 for that procedure. Many plans have exclusions for time periods and certain procedures. The EOB will indicate if the plan does not pay for a procedure, but that does not mean that the procedure was not needed or desired. Most insurance plans have restrictions on what they will cover and when they will cover treatment.
Additional Information EOB may Show
Explanation of Benefits can also show other important information like services submitted that are pending or that have been denied. Sometimes a claim may be filed by the dentist office, but the insurance company may request additional information before being able to complete or approve the claim. Services submitted that are pending status, have a request for additional information, or denial status often give a detailed explanation. Normally all information needed is submitted by the dental office on your behalf. An insurance company may deny coverage for a procedure based on the opinion of a dental expert. At that point a dental office will appeal the decision on your behalf and remind the dental expert that they did not conduct a clinical exam or speak to the patient concerning treatment options. It is considered below the standard of care for a dentist to determine treatment without doing clinical examination or considering the patient’s preferences. At Martin Dentistry our office submits all available records and information in order to avoid delays and additional requests.
Your Explanation of Benefits may initially seem complex, but with this explanation hopefully they will be easier to understand. After reviewing the information in your EOB, such as the claim, fees and payment please feel free to contact us here at Martin Dentistry with any additional questions you may have. We will be happy to further assist you.
Thank you,
Matthew Martin, DDS