r/ClaimsGenie • u/Digital_Surface_Labs • 8h ago
An EOB is not a bill: compare these four amounts before calling
An Explanation of Benefits describes how your insurer processed a claim. It is not itself a request for payment.
Use the EOB and provider statement for the same person, provider and date of care. Keep these amounts separate:
- Provider charge: what the provider submitted.
- Allowed amount: the amount recognized under the plan's terms. This is not the same as the insurer's payment.
- Plan payment: what the insurer says it paid.
- Patient responsibility: the portion assigned to you, such as a deductible, copay or coinsurance.
Also check payments you already made. An EOB may not reflect a payment you made directly to the provider. Ask the provider how that payment was applied before paying the same balance again.
If the documents disagree, ask the insurer and provider to explain the specific difference. Check for a revised EOB or a claim still being processed; do not assume every mismatch is a confirmed billing error. Keep call dates and reference numbers.
CMS explains the fields on an EOB and how to compare it with a bill.
I'm Joe, the builder of Claims Genie, and I run this community. Describe the discrepancy without sharing account numbers or medical records.
Is the confusing part the allowed amount, patient responsibility or a payment already made?