Read a Bill or Explanation of Benefits/Health Statement

Because doctors, labs, hospitals and other health care providers all charge different prices for the same services, knowing how to read a bill or Explanation of Benefits (EOB)/Health Statement will give you a better perspective on how much things really cost, how much the plan will pay and how much you owe. In addition, when you have a better understanding of costs, you’re more likely to spot any errors and avoid paying for someone else’s mistake.

What Are You Paying For?

Services billed by a hospital or doctor may include:

  • Your share of the cost for an office visit (if not collected on the date of service),
  • Specialized equipment,
  • Medications,
  • X-rays and other laboratory procedures, and
  • Hospital room and board.

What’s the Difference Between a Bill and an Explanation of Benefits/Health Statement?

  • Bills are issued by your doctor or another health care provider.In general, bills show the balance due and ask you to pay for your share of the cost. Sometimes, your provider may send a statement to you just to let you know your health plan has been billed, and sometimes it’s sent for one of the following reasons:
    • You are responsible for a deductible or coinsurance amount,
    • You received services that weren’t covered by your plan,
    • Your benefit limits were reached for specific services, or
    • The actual costs were above the reasonable and customary charges—that is, the maximum amount your plan has agreed to pay for a particular service.

    TIP: Always review bills carefully for mistakes, and never ignore a bill—even if you think you were improperly billed. Ignoring a bill can result in your provider referring the bill to a collection agency, which can impact your credit rating.

  • Explanations of Benefits/Health Statements are issued by your health plan. They list health care services that have been billed to the plan by the doctors and facilities you use, and compares the provider’s bill to your plan’s coverage. It shows the maximum allowable amount the plan will pay, the actual amount paid by the plan and any amount you owe.

    TIP:Get organized! Set aside a folder or large envelope to store all of your health care-related paperwork received during the year. That way, you’ll have everything from provider bills and receipts, to prescription receipts, to Explanations of Benefits/Health Statements—in one convenient place. You’ll never lose or misplace your health care paperwork again!

    • If you know the bill is wrong, contact the health care provider’s office and request a corrected bill. Then contact your plan’s member services department to make sure your claim has been paid correctly.
    • If you suspect the bill is wrong or your claim has been improperly processed, first verify that your plan works the way you think it does. If you still think a mistake has been made, contact your provider or your plan’s Member Services department to try to resolve the issue.

Avoid Losing Money: Compare Your Bill to Your Explanation of Benefits/Health Statement

Make sure you are being charged the correct amount by looking at your bill/statement and your Explanation of Benefits/Health Statement side by side. If you find a billing error, you should submit it to the Hospital Audit Reward Program. The Hospital Audit Reward Program may reimburse you, up to $500. Check out the details at S@W on the Nortel Intranet.

If Your Claim Is Denied

If your claim has been denied and you think an error has been made, first confirm that your plan actually covers the service in question. Remember, you have the right to appeal a denied claim. See the specific plan’s Summary Plan Description and review the appeals section to learn how to appeal a denied claim.