Explanation of Benefits – BellMedEx https://bellmedex.com Sat, 15 Mar 2025 12:08:17 +0000 en-US hourly 1 https://wordpress.org/?v=6.8.2 https://bellmedex.com/wp-content/uploads/2024/01/cropped-Favican-32x32.png Explanation of Benefits – BellMedEx https://bellmedex.com 32 32 How Long Should Providers Keep EOB Statements? A Complete Guide https://bellmedex.com/how-long-should-providers-keep-eob-statements/ Tue, 11 Mar 2025 14:38:58 +0000 https://bellmedex.com/?p=34413 If you’re a healthcare provider, you’ve likely wondered how long you should keep those Explanation of Benefits (EOB) documents.

Proper storage of EOBs isn’t just about keeping your office organized. But it’s also about protecting patient information, staying compliant with regulations, and having the records you need when billing questions arise.

You know the ones: a patient calls saying, “I don’t think I should’ve been charged for this,” or an insurance company asks, “Can you justify this claim?” With EOBs on hand, you’re ready to respond.

In this guide, we’ll walk through everything you need to know about EOB retention periods, from IRS guidelines to HIPAA requirements, and help you develop a storage system that works for your practice.

Keep your EOB documents for at least 7 years to comply with IRS tax guidelines. However, HIPAA has different requirements, mandating a 6-year retention period from creation or last use. Meanwhile, CMS sets the most variable standard, requiring between 5 and 10 years of retention depending on your provider type. Although these timelines differ, all three authorities agree that EOBs, despite being financial rather than clinical documents, must be properly maintained.

An EOB is a statement that insurance companies send to patients after they receive medical care. This document isn’t a medical bill. Instead, it explains what medical treatments and services the insurance company paid for on behalf of the patient. Each EOB breaks down:

  • The medical services provided
  • How much the provider charged
  • What portion the insurance covered
  • What the patient still owes (if anything)

Think of an EOB as a healthcare receipt that helps everyone understand who paid for what.

EOB usage

EOBs several important purposes which include:

✅ They Verify Billing Accuracy

EOBs help both you and your patients check that services were billed correctly. You can use them to spot errors before they become bigger problems, like charges for services that weren’t provided or incorrect procedure codes.

✅ They Help Resolve Billing Disputes Quickly

When questions arise about charges or payments, EOBs provide a clear record of what was billed and paid. Having these documents readily available can turn a potentially frustrating dispute into a quick resolution.

✅ They Provide a Clear Picture of Healthcare Costs

EOBs outline exactly what services cost, what insurance paid, and what patients owe. This transparency helps everyone understand the financial side of healthcare.

✅ They Help Track Healthcare Spending Patterns

By reviewing EOBs over time, you can identify trends in services, payments, and denials that might affect your practice’s financial health.

✅ They Clarify Insurance Coverage for Patients

EOBs help patients understand their insurance benefits, including coverage limits and out-of-pocket costs. This knowledge empowers them to make better healthcare decisions.

✅ They Help Detect and Prevent Fraud

Regular review of EOBs can reveal suspicious patterns or unauthorized charges, allowing you to address potential fraud early.

✅ They Demonstrate Compliance with Healthcare Regulations

During audits or investigations, EOBs serve as evidence that your billing practices follow state and federal regulations. Examples of applicable regulations include:

  • HIPAA (Health Insurance Portability and Accountability Act): Ensuring privacy and security of patient information tied to billing.
  • False Claims Act (FCA): Avoiding fraudulent billing by maintaining proper documentation like EOBs to substantiate services rendered and billed.
  • State Insurance Codes: Each state (e.g., California Insurance Code, Texas Insurance Code) has regulations governing claims processing, patient billing disclosures, and timelines for communication — EOBs help demonstrate that you’ve followed these requirements.

An Explanation of Benefits (EOB) is a formal document issued by insurance providers following the processing of healthcare claims. This document itemizes the services rendered, associated costs, insurance coverage applied, and the patient’s financial responsibility.

So are EOBs a part of the medical records? Here’s the answer:


Medical Records consist of clinical documentation that chronicles a patient’s health status and care.

These include:

  • Clinical notes and observations
  • Diagnostic test results
  • Treatment plans and medication orders
  • Progress notes and clinical correspondence
  • Surgical reports and procedural documentation

Financial Records, where EOBs are properly categorized, document the economic aspects of healthcare delivery.

These include:

  • Billing information and payment processing
  • Insurance claim documentation
  • Patient payment history
  • Cost accounting for services rendered

Explanation of Benefits (EOBs) are financial documents that detail insurance coverage and payment obligations, not clinical documentation, and thus remain separate from medical records. While medical records document a patient’s health status, diagnoses, and treatment plans, EOBs serve as financial instruments that track the monetary aspects of healthcare services, including insurance payments, patient responsibilities, and provider reimbursements.

Healthcare organizations maintain EOBs as part of their financial record-keeping systems, subject to different retention policies and regulatory requirements than those governing clinical documentation.

The Internal Revenue Service (IRS) is a federal agency that collects taxes and enforces tax laws. The IRS provides specific guidelines for keeping Explanation of Benefits (EOBs), which help taxpayers verify their medical expense deductions on tax returns.

Document TypeRetention PeriodPurpose
EOBs7 yearsVerify medical expense deductions
Tax Returns7 yearsGeneral recommendation for all tax documents
Medical Bills7 yearsSupport EOBs and deduction claims
Insurance Payment Records7 yearsConfirm portions paid by insurance vs. out-of-pocket
Prescription Records7 yearsSupport medication expense deductions

➜ Retention Period for EOBs

The IRS recommends that both healthcare providers and individuals keep EOBs for at least 7 years. This timeframe is important for several reasons:

Tax Deductions

EOBs serve as proof of medical expenses that can be claimed as deductions on tax returns. The IRS allows taxpayers to deduct qualified medical expenses that exceed a certain percentage of their adjusted gross income. Keeping EOBs for 7 years ensures you have the necessary documentation to support these deductions if questioned.

Audit Protection

The IRS can audit tax returns for up to 6 years if they suspect income underreporting of more than 25%. By keeping EOBs for 7 years, taxpayers can provide evidence of their medical expenses and avoid penalties.

Remember: Keeping organized records not only helps during potential audits but also makes your annual tax filing process much simpler.

When providing healthcare services, it’s important to follow federal regulations like HIPAA and CMS guidelines. These rules outline how Explanations of Benefits (EOBs) should be handled. This includes how they are delivered, stored securely, and how long they must be kept to protect patient privacy and ensure compliance.

hipaa cms guidelines for EOB statements
RegulationRetention PeriodExample
HIPAA6 years from creation or last useEOB from Jan 1, 2022 must be kept until Jan 1, 2028
CMS (Cost Reporting Providers)5 years after cost report completionCost report ending Dec 31, 2020 → keep records until Dec 31, 2025
CMS (Medicare Managed Care)10 years from contract terminationProgram ends Dec 31, 2020 → keep records until Dec 31, 2030

The Health Insurance Portability and Accountability Act (HIPAA) was created to protect patient health information. Under HIPAA, healthcare providers are required to maintain EOBs for 6 years from the date they were created or last used. This ensures that patient information is available if needed for audits, investigations, or other official purposes.

The Centers for Medicare & Medicaid Services (CMS) also set guidelines for retaining EOBs, depending on the type of healthcare service provider.

Under the general CMS retention rule for cost reporting, providers must keep all patient records, including EOBs, for 5 years after the completion of a cost report. This allows records to be available for review or audit.

Providers under Medicare Managed Care programs must retain EOBs and related records for 10 years. This longer period ensures full documentation of patient care and billing for potential audits.

When to keep:When safe to dispose:
➜ Until all payments are processed by insurance and provider

➜ Until any billing disputes are resolved

➜ Until your medical condition is completely resolved
➜ After 3 years if no outstanding issues

➜ If you aren’t claiming medical tax deductions

➜ When all payments have been settled by all parties

For routine medical care or one-time treatments, most healthcare experts recommend keeping EOBs for approximately 3 years. This timeframe allows patients to resolve any potential billing issues that might arise and provides adequate documentation for tax purposes if needed.

During this retention period, patients should organize their EOBs by keeping related documents together – for instance, grouping an office visit with any associated lab work or prescriptions. This organization helps patients track their deductible status throughout the year and ensures they can quickly identify any duplicate billings.

Once three years have passed, patients can typically dispose of these records if all payments have been settled, no billing disputes remain, and they aren’t claiming medical tax deductions. However, if there’s any uncertainty, it’s always better to retain these documents longer.

When to keep:When safe to dispose:
➜ For ongoing or recurring health issues

➜ When balance remains due

➜ When there are billing discrepancies

➜ If claiming medical expenses on tax returns
➜ For chronic conditions, keep records 5 years after final treatment

➜ For tax purposes, keep records 7 years after claiming deduction

For patients managing serious or chronic health conditions, the retention guidelines become more stringent. In these cases, medical experts recommend keeping EOBs and related medical records for 5-7 years, depending on circumstances.

Patients dealing with ongoing health issues should establish a more comprehensive filing system, preferably organizing documents chronologically while still maintaining related services together. This approach creates a valuable historical record that can help providers understand treatment histories and insurance coverage patterns over time.

For chronic conditions specifically, patients should retain all records for at least 5 years following their final treatment date. If they’re claiming medical expenses as tax deductions, this retention period extends to 7 years after filing the tax return, in accordance with IRS requirements.

Medical records must stay in file cabinets or computer systems for different lengths of time. Doctors cannot throw them away early because they might need them later. The government has rules about keeping these papers. Patients also expect their health stories to be available when they return for more care.

There are many kinds of health records, and each type stays for a different amount of time. The guide below shows how long each type should be kept. Healthcare workers should know these timeframes. This ensures they do not lose important information that could save a life someday.






EOBs are the papers from insurance companies that show what medical care the patient got and who paid for it and they have important information that must be kept safe and organized so both the patient and the healthcare provider can find them when they need them and so others cannot see those private health details. The way you store these papers matters because good storage saves time and keeps information private and follows the laws about medical records.

▶ Physical Storage Solutions for EOBs

When you have paper EOBs that you can hold in your hand, you need to put them somewhere safe where they will not get lost or damaged or seen by people who should not see them and this means thinking about special places to keep them.

➜ Secure File Cabinet Systems

Tip: Keep paper EOBs in a locked, fireproof, and waterproof file cabinet where only certain people can open it.

The paper EOBs should go in a strong cabinet that has locks on the drawers and will not burn in a fire and will stay dry if water spills and the cabinet should be:

  • Locked all the time so no one can just open it and look inside
  • Made to not burn even in very hot fires for at least half an hour
  • Built to keep water out if pipes break or sprinklers turn on
  • Placed in a room where not many people walk through
  • Hard to open without someone knowing it was opened

Buying a good strong cabinet costs money but it keeps patient information safe and follows the laws about privacy in healthcare.

➜ Logical Filing and Categorization

Tip: Make a simple system with different colored folders and clear labels so you can find papers quickly.

You should organize your files in a way that makes sense so you can find what you need without looking through every paper:

  • Use folders that are different colors for different insurance companies or different years
  • Put the patient folders in ABC order so names are easy to find
  • Write clearly on each folder the patient name and when they got care and which insurance they had
  • Make a list that shows how your filing system works
  • Sometimes put information in more than one place if it belongs in more than one category
  • Keep track of who takes folders out so nothing gets lost

When your filing system works well, you can find what you need in seconds instead of minutes and this makes your work easier every day.

▶ Electronic Storage Systems

Keeping EOBs on computers or in the cloud takes less space and lets you search for things quickly but you must be very careful about computer security so private information stays private.

➜ Encrypted Storage Solutions

Tip: Use special healthcare computer systems that scramble the information so hackers cannot read it.

When you store EOBs on computers:

  • Use computer programs made specially for healthcare information
  • Make sure all information is scrambled with strong codes when it travels and when it sits on the computer
  • Check that any cloud service has signed papers saying they will protect health information
  • Think about using healthcare document systems instead of regular storage like normal Google Drive
  • Set up two different ways to prove who you are when you log in
  • Have a plan for managing the secret codes that unscramble the information

Remember that regular cloud storage like basic Dropbox is not automatically safe enough for health information without extra security steps and special agreements.

➜ Comprehensive Backup Procedures

Tip: Always have three copies of your EOB information in different places.

A good backup plan means:

  • Having the original information plus two backup copies
  • Keeping backups on different types of storage like your computer and also the cloud
  • Having one backup in a different building
  • Setting up automatic daily backups of new information
  • Doing complete backups every week
  • Checking monthly that you can actually get your information back from the backups
  • Writing down the steps for how to recover information if something goes wrong

This way even if computers crash or buildings burn down your important EOB information will not be lost forever and you should regularly test your backups to make sure they work.

➜ Granular Access Controls

Tip: Control exactly who can see which EOBs and keep track of who looks at them.

Protect electronic EOBs by carefully managing who can see them:

  • Give each staff member only the access they need for their job
  • Make it so some people can look but not change information
  • Set computers to log out automatically if no one uses them for a while
  • Keep detailed records of who looked at which documents and when
  • Regularly check the list of who has access and remove people who no longer need it
  • Give each staff member their own login and never share accounts
  • Make everyone change their passwords every few months

These steps not only keep patient information safe but also show exactly who looked at what information and when they looked at it.

▶ Organization of Patient Data

How you organize your EOBs makes a big difference in how easily you can find them when you need them and a good system saves time and reduces frustration.

➜ Chronological and Categorical Sorting

Tip: Organize EOBs by patient name, then by date, then by type of medical service.

Design your filing system to help find information in different ways:

  • First organize by patient name or ID number
  • Then organize by year and month
  • Then organize by what kind of medical service it was
  • Make it possible to find all records for family members if needed
  • Keep newer active records separate from older archived records
  • Have clear steps for moving records from active to archive status
  • Create special ways to get records quickly in emergencies

This system with multiple layers works well because sometimes you need to find recent activity and sometimes you need to find all records for one kind of medical service and sometimes you need a patient’s complete history.

➜ Searchable Metadata Implementation

Tip: Add extra information to each EOB file so you can search for many different things.

For computer systems, make searching easier by including:

  • Patient information like name, birth date, and ID numbers
  • Doctor information like name and facility
  • Dates when service happened and what kind of service it was
  • Claim numbers and whether they were paid
  • Insurance plan details
  • How much was paid and adjusted
  • Medical codes for diagnosis and procedures
  • Special tags for unusual cases or common searches

When you add all this extra information, your simple file storage becomes a powerful system that can quickly answer complex questions like “Show me all EOBs for heart procedures done in March that patients still need to pay.”

▶ Retention and Disposal Protocols

Your storage plan should include clear rules about how long to keep records and how to safely get rid of them when that time is up.

➜ Scheduled Review System

Tip: Every three months, check for records that no longer need to be kept.

Create a system to:

  • Mark records that are getting close to the end of their keeping time
  • Look at each marked record to see if there is any special reason to keep it longer
  • Write down all decisions about keeping or not keeping with reasons why
  • Schedule safe destruction for records that can be removed
  • Keep a list of what was destroyed and when it happened

Medical records like EOBs must be destroyed carefully to protect patient information. Here’s how to do it right:

Destroying Paper Records

Paper medical records can be seen by the wrong people if not destroyed properly.

  • Use a cross-cut or micro-cut shredder that cuts paper into tiny pieces
  • Consider hiring professional shredding services – they give you a certificate proving destruction
  • On-site shredding happens at your location so you can watch
  • Regular shredding services work well for medical offices with many records

Destroying Digital Records

Deleting files normally doesn’t really remove them from your computer.

  • Use special wiping software like DBAN or BitRaser that truly erases files
  • Encrypt (scramble) sensitive files before deleting them for extra protection
  • For complete safety, physically destroy old hard drives, USB drives and CDs

Important Steps to Remember

  • Keep track of which records you destroy and when
  • Train all staff on proper record destruction
  • Check local laws about how long to keep records before destroying
  • Make sure any company you hire signs agreements to protect patient information

Different U.S. states have different rules about how long doctors and hospitals must keep medical records. Here’s what you need to know:

  • Most states say to keep records for 5-10 years
  • Records for children usually must be kept longer – until they become adults (age 21) or even longer
  • Some states use simple language like “keep as long as needed” (Alabama)
  • A few states have special rules:
    • Hawaii has different times for “Full” records versus “Basic” records
    • Some states have separate rules for hospitals and private doctors

While many states follow the basic federal HIPAA rule (keep records for 6 years), always check your state’s specific rules to make sure you’re following the law correctly.

Below is a table summarizing the retention periods for medical doctors and hospitals, with distinctions for adults and minors where applicable:

StateMedical Doctors (Years)Hospitals (Years)
AlabamaAs long as necessary for treatment and medical legal purposes5
Alaska6 (HIPAA)Adult: 7 after discharge; Minor: 7 after discharge or age 21, whichever longer
ArizonaAdult: 6 after last service; Minor: 6 after last service or age 21, whichever longerAdult: 6 after last service; Minor: 6 after last service or age 21, whichever longer
Arkansas6 (HIPAA)Adult: 10 after last discharge (master index permanently); Minor: 2 after age 18 (until 20)
California6 (HIPAA)Adult: 7 after discharge; Minor: 7 after discharge or age 18 (until 19), whichever longer
Colorado6 (HIPAA)Adult: 10 after last care; Minor: 10 after age 18 (until 28)
Connecticut7 from last treatment, or 3 after death10 after discharge
Delaware7 from last entry6 (HIPAA)
District of ColumbiaAdult: 3 after last seen; Minor: 3 after last seen or age 18 (until 21)10 after discharge
Florida5 from last contactPublic: 7 after last entry
Georgia10 from record creationAdult: 5 after discharge; Minor: 5 past age 18 (until 23)
HawaiiAdult: Full 7 after last entry, Basic 25 after last entry; Minor: Full 7 after age 18 (until 25), Basic 25 after age 18 (until 43)Adult: Full 7 after last entry, Basic 25 after last entry; Minor: Full 7 after age 18 (until 25), Basic 25 after age 18 (until 43)
Idaho6 (HIPAA)Clinical lab: 5 after test date
Illinois6 (HIPAA)10
Indiana77
IowaAdult: 7 from last service; Minor: 1 after age 18 (until 19)6 (HIPAA)
Kansas10 from service providedAdult: 10 after last discharge; Minor: 10 or 1 after age 18 (until 19), whichever longer; Summary: 25
Kentucky6 (HIPAA)Adult: 5 from discharge; Minor: 5 from discharge or 3 after age 18 (until 21), whichever longer
Louisiana6 from last treated10 from discharge
Maine6 (HIPAA)Adult: 7; Minor: 6 past age 18 (until 24); Patient logs/x-ray reports: permanently
MarylandAdult: 5 after record made; Minor: 5 after record or age 18+3 (until 21), whichever laterAdult: 5 after record made; Minor: 5 after record or age 18+3 (until 21), whichever later
MassachusettsAdult: 7 from last encounter; Minor: 7 from last encounter or age 9, whichever longer30 after discharge or final treatment
Michigan7 from date of service7 from date of service
Minnesota6 (HIPAA)Most: permanently (microfilm); Misc: Adult 7, Minor 7 after age 18 (until 25)
Mississippi6 (HIPAA)Adult sound mind: 10, death: 7; Minor: minority period + 7
Missouri7 from last serviceAdult: 10; Minor: 10 or until 23, whichever later
Montana6 (HIPAA)Adult: 10 after discharge/death; Minor: 10 after age 18/death (until 28); Core: additional 10 years
Nebraska6 (HIPAA)Adult: 10 after discharge; Minor: 10 or 3 after age 18 (until 22), whichever longer
Nevada5 after receipt/production5 after receipt/production
New Hampshire7 from last contact, unless transferredAdult: 7 after discharge; Minor: 7 or until 19, whichever longer
New Jersey7 from most recent entryAdult: 10 after discharge; Minor: 10 after discharge or until 23, whichever longer; Summary: 20
New MexicoAdult: 2 beyond insurance/Medicare/Medicaid; Minor: 2 after age 18 (until 20)Adult: 10 after last treatment; Minor: age 18+1 (until 19)
New YorkAdult: 6; Minor: 6 and 1 after age 18 (until 19)Adult: 6 after discharge; Minor: 6 after discharge or 3 after age 18 (until 21), whichever longer; Deceased: 6 after death
North Carolina6 (HIPAA)Adult: 11 after discharge; Minor: until 30th birthday
North Dakota6 (HIPAA)Adult: 10 after last treatment; Minor: 10 after last treatment or 21, whichever later
Ohio6 (HIPAA)6 (HIPAA)
Oklahoma6 (HIPAA)Adult: 5 beyond last seen; Minor: 3 past age 18 (until 21); Deceased: 3 after death
Oregon6 (HIPAA)10 after last discharge; Master index: permanently
PennsylvaniaAdult: 7 from last service; Minor: 7 from last service or 1 after age 21 (until 22), whichever longerAdult: 7 after discharge; Minor: 7 after age 18 or as long as adult, whichever longer
Puerto Rico6 (HIPAA)6 (HIPAA)
Rhode Island5 unless otherwise requiredAdult: 5 after discharge; Minor: 5 after age 18 (until 23)
South CarolinaAdult: 10 from last treatment; Minor: 13 from last treatmentAdult: 10; Minor: until 18 and 1 year after (usually until 19)
South DakotaInactive or whereabouts unknownAdult: 10 from visit; Minor: 10 from visit or age 18+2 (until 20), whichever later
TennesseeAdult: 10 from last contact; Minor: 10 from last contact or 1 after age 18 (until 19), whichever longerAdult: 10 after discharge/death; Minor: 10 after discharge or minority+1 (until 19), whichever longer
TexasAdult: 7 from last treatment; Minor: 7 from last treatment or until 21, whichever laterAdult: 10 after last treated; Minor: 10 after last treated or until 20, whichever longer
Utah6 (HIPAA)Adult: 7; Minor: 7 or age 18+4 (until 22), whichever longer
Vermont6 (HIPAA)10
VirginiaAdult: 6 after last contact; Minor: 6 after last contact or age 18/emancipation, whichever longerAdult: 5 after discharge; Minor: 5 after age 18 (until 23)
Washington6 (HIPAA)Adult: 10 after discharge; Minor: 10 after discharge or 3 after age 18 (until 21), whichever longer
West Virginia6 (HIPAA)6 (HIPAA)
Wisconsin5 from last entry5
Wyoming6 (HIPAA)6 (HIPAA)

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EOB in Medical Billing: A Guide for Providers https://bellmedex.com/eob-in-medical-billing-a-guide-for-providers/ Thu, 02 May 2024 14:35:34 +0000 https://bellmedex.com/?p=28803

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An Explanation of Benefits (EOB) is equally important for patients and providers. It helps identify billing errors in claims and enables providers to fix them to avoid claim denials. EOBs improve the overall effectiveness of billing and patient communication in medical practices.

The healthcare providers should properly check the details in EOB to understand the fixes. They must collaborate with patients to address the mistakes that the insurer pointed out in the document to streamline the billing process.

This guide helps providers understand the EOB in medical billing, its significance, components, workflow, and actionable steps to optimize billing processes by taking help from the EOB document.

What Is EOB In Medical Billing?

“EOB” in medical billing stands for “Explanation of Benefits.” The EOB is a document an insurance company sends to a covered individual (patient) explaining what medical treatments and/or services were paid for on their behalf. It details the services’ costs, how much was covered by the insurance, any discounts applied, and what the patient is responsible for paying.

This document is not a bill but a breakdown of how the insurance claim was processed and what portion, if any, the patient owes to the healthcare provider.

To understand the differences between an Explanation of Benefits (EOB) and a Medical Bill, see the comparison table below:

EOB Vs Medical Bill: A Comparison

FeatureEOBMedical Bill
PurposeTo summarize the insurance claim process, show what the insurance paid and what you owe.To request payment for healthcare services provided.
Sent byYour insurance company.Your healthcare provider.
DetailsDetails what the insurance company covered, including paid amounts and patient’s responsibility.Details the total charges and specifies the amount due from the patient.
Action RequiredNo direct payment is made in response to an EOB. It is informational.Payment is required. This is a bill you need to pay.
TimingSent after the insurance processes your healthcare provider’s claim.Sent after your insurance has settled its portion and determined your share of the cost.
ItemsThis includes the date of service, type of service, provider, charges from the provider, what insurance is covered, and what you owe.Includes date of service, type of service, total charges, and your specific payment responsibility (deductibles, copayments, etc.).

Why Are EOBs Essential For Providers?

Explanation of Benefits (EOBs) are essential documents insurance companies provide that outline the services delivered to a patient, how much the insurance company paid, and what a patient has to pay the provider.

EOBs are essential for both patients and healthcare providers.

Here’s why they are essential for providers:

Ensures the Accuracy of Services and Providers 

EOBs list the services the healthcare providers deliver to their patients. Reviewing this document helps ensure that all listed services were provided and that there are no errors, such as services that a provider did not deliver to the patient. In this way, EOBs help providers avoid overcharges or fraudulent claims.

Identifies Errors in Billing and Insurance 

EOB helps providers compare a medical bill issued by an insurance company and the actual payment a patient pays. Providers can check the differences in billing information and insurance details. The provider can fix this issue if there is any inconsistency or mismatch between these two. So, EOBs can help providers address billing and insurance errors.

Assists in Payment Plans and Financial Options

Providers can review the costs (check the detailed breakdown costs mentioned by insurers) using EOBs in case of unexpected extra charges. The provider can easily discuss and negotiate the various payment options, such as setting up a payment plan or exploring other financial assistance options if the bills are too high for immediate payment.

Records Documentation for Disputes and Appeals

When a patient wants to appeal a decision made by the insurance company, he disputes a charge from the provider or clarifies tax deductions related to medical expenses. In this case, EOBs assist providers in sorting out the confusion of your patient. This contains a record of services and charges essential for appeals and disputes.

Ensure Compliance with Tax Regulations

EOBs can be used for tax purposes to verify medical expenses, especially when patients are itemizing deductions for healthcare costs on their tax returns. This can be important for ensuring providers claim the correct amounts and comply with tax regulations regarding medical expenses.

Components of an Explanation of Benefit (EOB)

There are various components of the Explanation of Benefit (EOB). Each provides a comprehensive overview of the claim and its financial implications.

EOB Components

Here’s what an EOB document may have:

➜ Patient Information: This section includes the insured individual or policyholder’s name, address, policy number, and other relevant details.

➜ Provider Information: This contains the name, address, and contact information of the healthcare provider who rendered the services.

➜ Claim Details: This consists of the services rendered and claim details, such as the service date, the description of the procedure or treatment, the claim no, and the billing codes.

➜ Billed Charges: The EOB shows the total charges billed by the healthcare provider for the services rendered. This amount represents the initial cost of the medical care before any adjustments or insurance coverage.

➜ Allowed Amount: The insurer wants to pay the maximum amount for the services rendered. This amount is the negotiated rate between the provider and the insurance company or based on the provider’s fee schedule.

➜ Insurance Coverage: These are the billed charges that the insurance company will cover. It includes deductibles, coinsurance, copayment amounts, and applicable limitations or exclusions.

➜ Patient Responsibility: This is the amount the patient is responsible for paying out-of-pocket. This may include copayments, deductibles, coinsurance, or any remaining balance after the insurance company’s payment.

➜ Payment Information: This is the information on the payment made by the insurance company to the healthcare provider. It includes the amount paid, the payment date, and any adjustments or write-offs applied.

➜ Remaining Balance: This is the remaining amount that the patient has to pay. This may include the non-covered services, the patient’s share of the allowed amount, or other outstanding charges.

Learn: How to read an EOB Document.

The Workflow of an EOB

The workflow of an Explanation of Benefits (EOB) is crucial for healthcare providers, ensuring accurate billing and timely payment for services rendered.

EOB Workflow

Let’s discuss the EOB workflow:

Patient Visit

  • The EOB workflow starts when a patient visits a doctor and receives any service like a routine checkup, diagnostic test, etc.
  • The physician documents the patient’s details, including the reason for the visit, any diagnosis made, and treatments provided.

Service Rendered

  • The provider performs the necessary medical services based on the patient’s health needs.
  • The physician ensures all services are medically necessary and correctly documented in the patient’s medical records.

Claim Submission

  • The provider, or their billing office, compiles a detailed bill for services rendered and sends it to the patient’s insurance company via a clearinghouse.
  • Provider submits all necessary service codes, patient information, and required documentation accurately.

Processing by Insurance

  • Once the insurance company receives the claim, it processes it to determine the coverage and the amount payable.
  • The provider may need to respond to queries from the insurance company or provide additional documentation if required.

EOB and Payment Issued

  • After processing the claim, the insurance company issues an EOB to the provider, which details what has been covered, any deductions, and the final amount paid. Payment is usually made by check or electronic funds transfer (EFT).
  • Review the EOB for accuracy, ensure the payment matches the EOB details, and address any discrepancies with the insurance company.

💡 Pro Tip for Providers:

Providers should partner with an efficient clearinghouse to reduce the chances of denied claims. A clearinghouse checks the claim details by claims scrubbing and integrating billing software. This can ensure accuracy in claim details before submission, minimizing billing errors.

Electronic Payment Process for Providers

Healthcare providers need to make transactions secure and transparent. There are two ways they can complete the payment process electronically:

  • Electronic Funds Transfer (EFT)
  • Electronic Remittance Advice (ERA)

EFT and ERA help providers save time, reduce errors, and ensure compliance with HIPAA regulations. Additionally, providers can make secure and transparent transactions.

Providers can create the EOB as an electronic file, usually in a format called an 835, and can download the ERA 835 file from the clearinghouse.

Electronic Funds Transfer (EFT)

According to CMS.gov, Electronic Funds Transfer (EFT) transmits healthcare payments from a health plan to a healthcare provider’s bank.

An EFT transaction contains payment processing information such as:

  • Amount being paid
  • Names and identification information of the payer and payee
  • Bank account information for the payer and payee (including routing and account information)
  • Date of payment

Electronic Remittance Advice (ERA)

According to CMS.gov, electronic remittance advice, or ERA, is an explanation from a health plan to a provider about a claim payment. An ERA explains how a health plan has adjusted claim charges based on factors like:

  • Contract agreements
  • Secondary payers
  • Benefit coverage
  • Expected copays and coinsurance

Healthcare providers can connect an EFT with the services they provide to their patients using ERA. This helps providers and health plans track transactions, making the payment process secure and streamlined.

💡 Pro Tip for Providers:

Healthcare providers must develop transparent and swift communication (sending e-mails, reminders, and SMS alerts) with their patients to address errors, such as mismatched details regarding insurance providers, patients, and claims. This can help them to avoid the denied claims and improve the billing process.

What Providers Should Do When They Receive EOB Receipt?

Upon receiving the ERA, the provider’s office should perform the following steps:

EOB Receipt Medical Billing

1). Payment Posting:

Payments must be applied to the correct patient accounts based on the information in the ERA. To efficiently post payments, the following details included in the EOB are essential:

  • Payer Name and Address: The name and address of the insurance company making the payment.
  • Patient Name: The name of the patient receiving the service.
  • Provider Name and Address: The healthcare provider’s details.
  • Member ID#: The policy identification number of the patient.
  • Claim received Date: The date the payer received the claim from provider.
  • Payment or denial date: The date the claim processed or denied by payer.
  • Date of Service (DOS): The date service provided from provider to patient.
  • CPT Code: Procedure code
  • Billed Amount: The Amount for each service performed by providers.
  • Claim Number: Number assigned by the payer for each claim.

2). Handle Secondary Claim

If the patient has secondary insurance, any remaining balances after the primary insurance’s payment should be billed to the secondary insurer.

  • Allowed Amount: The amount suitable according to the payer for a specific service. AA = PA+ PR.
  • Paid Amount: Paid Amount = Allowed Amount – Patient responsibility.
  • Patient Responsibility: This is the balance percentage of reimbursement the patient must pay according to his policy with the insurance company. If they have one, the patient or his secondary insurance pays this.
  • Write-off Amount: It is an amount that the provider waives off. Write-off amount = Billed Amount – Allowed Amount.

3). Billing Patient Balances

If there’s any amount due that is the patient’s responsibility and not covered by any insurance, the provider should bill the patient directly.

4). Address Claim Denials

If the insurer denies the claim, the provider must identify the reason for rejection and the denial code to resubmit the claim accurately.

Enhance Payment Processing with BellMedEx

If you’re in the medical business, paying and getting paid on time is important.

BellMedEx medical billing company has a solution for that!

We can set you up to manage your finances electronically using our patent Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) systems.

Our automated medical billing solutions follow the rules laid out in the HIPAA, so you stay compliant. More than that, we make the whole payment process quick and secure.

Here’s how our smart solutions are helping providers of all practices:

Better Efficiency: BellMedEx allows providers to enroll with various payers through advanced PMS software and receive payments directly to their bank account via the Automated Clearing House (ACH) network.

Comprehensive ERA Services: Providers can get detailed electronic explanations of benefits (EOBs), which include adjustments, deductions, and detailed reasons for denial, all accessible within our platform.

Real-Time Updates: Enables providers to track payment statuses in real-time view, print, download, or export ERAs in multiple formats.

Final Thoughts

Healthcare providers cannot ignore the importance of EOB in medical billing. It is equally essential for patients and providers.

EOB documents give providers a roadmap to address billing issues, such as claim errors, inaccurate insurance details, etc.

Choosing proper payment plans, utilizing fund transfer tools like EFT and ERA, and partnering with an experienced clearinghouse like BellMedEx streamlines the payment posting process.

In a nutshell, EOB makes the transaction process easy and enables you to focus on quality patient care, which is the ultimate goal of every provider.

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