Explanation of Benefits

Making Sense of Your Medicare Explanation of Benefits (EOB) Statement

How do you know your Medicare Explanation of Benefits (EOB) Statement?

It might be easy for a health insurance provider to decipher, but it’s unclear when the health insurance company is involved.

You can find out how the EOB statement works in this post from an expert on health care.

Table of Contents

Medicare Explanation of Benefits (EOB)

What is an Explanation of Benefits Statement (EOB)?

An EOB statement is a document that shows you the costs for any prescriptions you filled during the previous month. You receive an EOB each month you use your Medicare plan to fill a prescription. The EOB helps you see how prescription drug expenses are distributed between your health plan and copayment.

The information on your EOB includes:

  • The date of covered services
  • The name of the provider
  • A description of the services provided
  • The approved amount billed to Medicare for each service
  • The amount paid by Original Medicare, and
  • The amount you are responsible for (copayment or coinsurance)

Eight Tips Related to Your Medicare Advantage EOBs Statement

Here are ten tips I have learned that will help you look beyond the confusion into how they translate directly into money saved:

  1. Look for specific services first – some health benefits may not appear on an EOB because Medicare does not cover them.
  2. Be mindful of the dates – for example, if your doctor prescribed medication on January 1 and you started taking it that same day. Only prescriptions made after January 2 will appear in your EOB statement.
  3. Count how many visits each service appears under – this is an easy way to compare apples to oranges when comparing bills from different providers (i.e., count how many times a specific provider charged for services).
  4. Look for duplicate services – if you received an injection on two different dates, likely, the same provider charged twice for the service.
  5. Check how many of each type of service you received – this will help you determine if the amount billed was reasonable.
  6. Look for services not covered by your plan – these may include items or services that were not medically necessary, or they may be a product that your plan does not cover.
  7. Look for services you did not receive – if this is the case, you will likely have to pay the amount of the service.
  8. If you have questions about the accuracy of a charge – call your provider’s billing department and ask for an explanation. Your doctor or another provider may be willing to work with you to help you better understand your statement.

Is my Explanation of Benefits I Received a bill?

No, the Explanation of Benefits is not a bill.

The Explanation of Benefits is a statement of the medical services you received and details on how you and your plan will share costs.

The EOB may include:

  • A list of the medical services you received
  • The date(s) of service
  • The amount charged for each service
  • Any applied discounts or adjustments
  • How much does Medicare pay for each service
  • How much you may owe for each service
Medical documents

How do I get a Medicare Explanation of Benefits?

How do I get my EOB? You can get your EOB online or through the mail. You must enroll in the Medicare Online Account Center to receive your EOB online.

If you want to receive your EOB through the mail, follow these steps:

  1. Call 1-800-MEDICARE (1-800-633-4227).
  2. Tell the person who answers your call that you want to receive your EOB through the mail.
  3. The person will give you a mailing address to send your request.
  4. Send the completed form (you can get this from your Social Security office) to your given address.
  5. After we receive your request, it will take about two weeks for us to send you your EOBs. If there is a delay in receiving your request, we will send you a letter explaining why.

How do you Read your Medicare EOB Letter?

Your explanation of benefits letter summarizes the costs associated with your care. The EOB letter contains a glossary of terms and definitions, as well as instructions for how to appeal a claim. 

The EOB letter may also reflect what portion of your out-of-pocket medical expenses count toward your annual deductible. 

To read your EOB letter:

  • Look for the date of service. This will be listed at the top of the page, along with the provider’s name and address.
  • Find the charges for each service you received. These will be itemized on the statement.
  • Compare the charges to the amount that your insurance company paid. You may need to contact your provider or insurance company to resolve the issue if there is a discrepancy.
  • Review any adjustments made to the charges. These could include things like discounts, write-offs, or co-pays.
  • Check to see if there are any outstanding balances that you are responsible for paying.
Review Documents

What do you do with the Explanation of Benefits?

An Explanation of Benefits, or EOB, is a statement from your Medicare plan that tells you (and sometimes your doctor) what was covered after you received care. You should check your EOB for mistakes or signs of fraud.

You can also use your EOB to compare medical receipts against claims listed on the EOB. This can help you make sure you were charged the correct amount.

In some cases, you may be able to get more information about a claim by calling the customer service number on your EOB.

You can also use your EOB to check the progress toward satisfying the required deductibles for your plan.

Can I View and Download my Medicare EOB online?

Yes, you can view and download your Medicare EOB online. You must log into your account on your insurance provider’s website to view your EOB. 

However, you can also download your Medicare EOBs online. With paperless EOBs, you can access your EOB states for up to 36 months.

If you wish to keep your statement for longer than 36 months, we recommend downloading your EOBs to your personal computer.

You can also check the status of your current Medicare claims online. You can log into your Medicare account and download the claims information.

Questions about Medicare Coverage

What if I have questions about my EOB Statement?

You can contact your health care provider if you have questions about your Medicare Explanation of Benefits (EOB) Statement. You may want to appeal your case through the Medicare EOB appeals process if there are discrepancies between the medical payment receipts and the amounts listed in the EOB.

Part D Medicare Prescription Drug Coverage EOB

You can save on prescription drug costs by proactively monitoring increases in your drug prices. Consult your doctor to check if you can replace your current prescription drugs with alternative, lower-cost medicines, such as generic drugs.

If you recently switched to another Part D prescription drug plan, ensure that your previous plan accurately transferred your amounts. Also, check whether regular adjustments, like reverse claims, took effect. Your EOB is also a supporting document in filing for medical tax deductions.

You may need to switch to a new Part D or Medicare Advantage plan with better prescription drug coverage if your current plan is no longer cost-effective.

Our Medicare insurance agents can help you navigate this process, finding you an updated Part D plan that provides improved prescription drug costs.

Is Medicare Summary Notice the same as Explanation of Benefits?

An EOB, or Explanation of Benefits, is a notice you will receive from your Medicare Advantage Plan or Part D prescription drug plan after receiving medical services or items. 

You will only receive an EOB if you have Medicare Advantage or Part D. It is important to remember that an EOB is not the same as a Medicare Summary Notice and is also not a bill.

While these two documents are similar, the Medicare Summary Notice is the Medicare version of the EOB, making them different. 

What is the Medicare Summary of Notice?

If you’re a Medicare beneficiary, you’re likely familiar with the Medicare Summary Notice (MSN). The MSN is a quarterly notice summarizing your Medicare services and the costs for those services.

It’s important to review your MSN thoroughly to verify that you received the services you needed and that you were charged the correct amount for them.

The MSN lists the service dates, the service type, the provider, and the amount charged. It also shows any Part B or Part D deductible amounts that you’re responsible for. If you have a Medicare Advantage Plan, the MSN will show any copayments or coinsurance amounts you owe.

You can contact the provider directly if you have questions about any of the services or charges listed on your MSN. If you think you were charged incorrectly, you can file a formal complaint with Medicare.

It’s essential to keep track of your monthly services received and the charges you accrue to budget for your healthcare costs. The Medicare Summary Notice can help you identify your out-of-pocket costs.

Please review it carefully every quarter and contact Medicare or your provider with any questions or concerns.

What if I think there's a mistake on my EOB?

If you think there’s a mistake on your EOB, you can contact the provider and Medicare to bring up your concerns.

The EOB summarizes the costs associated with your care, but it is not a bill.

Page 1 of an EOB shows a glossary of terms, definitions, and instructions for how to appeal a claim, if necessary.

Page 2 of an EOB may contain more specific details about the cost of the care you received.

Additional information on an EOB may include language assistance instructions and more specific details about filing an appeal in your state of residence.

How can you avoid paying late enrollment penalties when you turn 65?

How do I Appeal a Decision on my EOB?

If you disagree with a coverage or payment decision made by Medicare or your Medicare plan, you can file an appeal. For example, you can appeal if Medicare or your plan denies:

  1. A request for a health care service, supply, item, or drug you think Medicare should cover.
  2. A request for payment of a health care service, supply, item, or drug you already received.
  3. A request to change the amount you must pay for a health care service, supply, item, or drug.

You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or drug you think you still need.

Another type of appeal is an at-risk determination made under a drug management program that limits access to coverage for frequently abused drugs, like opioids and benzodiazepines.

Instructions on how to appeal a decision are located on your EOB on page 3. Page 2 of your EOB will reflect the costs of the medical services you received.

What other sources of information about my EOB are available?

Your EOB is just one way to get information about your medical claims and payments. Other sources of information may include:

– Your health plan’s website or member portal

– The provider’s billing statement

– Calling the customer service number on your insurance card

Do I need to Store my files

Is it necessary to keep Medicare summary notices?

Tax preparers recommend keeping your Medicare summary notices (MSNs) for six to seven years. MSNs are essential because they record your health care services and products. They also show how much Medicare paid for those services and products. It’s standard to keep your MSNs for at least one full calendar year.

You can file an appeal if Medicare denies your request for a health care service or product. The appeals process has five levels:

  1. Redetermination by the MAC
  2. Reconsideration by Qualified Independent Contractor
  3. An administrative Law Judge hearing
  4. Review by the Departmental Appeals Board
  5. Judicial review in federal court

If you disagree with the decision made at any process level, you can usually appeal to the next level. Keep in mind there is a limited amount of time to file an appeal, so ensure you file promptly.

What is the Allowed amount on an EOB?

The allowed amount is the total amount that your insurance plan will pay for a healthcare service. The authorized amount is not related to any claims you may have made, and your plan determines it.

You will not receive an EOB if you have no claims during the reporting month or if you are eligible for both Medicare and Medicaid.

How do you Detect Fraud in my Medicare Explanation of Benefits (EOB) Statement?

Fraud in your Medicare Explanation of Benefits (EOB) Statement can be detected in several ways. First, if you see something that doesn’t look right or seems out of the ordinary, you should contact your doctor or the medical facility where you received care to get more information. 

It’s also a good idea to keep track of your own medical services and procedures so that you can compare them to the EOB Statement. If you see something on the statement that you don’t recognize or that doesn’t match up with your records, this could be a sign of fraud.

Another way to detect fraud is to look for red flags associated with fraudulent activity. These can include things like unusual medical billing codes, charges for services that you didn’t receive, or duplicate charges. 

If you see any of these red flags, you should contact your Medicare provider right away to get more information.

If you think that you may have been the victim of fraud, it’s essential to report it to the proper authorities. 

You can contact the Office of Inspector General at 1-800-HHS-TIPS (1-800-447-8477) to report any suspected fraud, waste, or abuse in the Medicare program

You can also file a complaint with the Federal Trade Commission at 1-877-FTC-HELP (1-877-382-4357).

How do I Contact Billing Office Customer Service if I have Concerns about my Hospital Bill?

The Medicare billing office customer service can be contacted by phone. You may want to look at the statement and compare it with your hospital bill, making note of any errors or additional charges that you may not have expected. 

If you would still like to contact billing office customer service, call the number on the statement and speak with a representative who can help answer your questions or take care of any issues you may have.

Now that you know how to read and understand your Medicare EOB statement, you can be sure that you’re getting the most out of your benefits. Keep these tips in mind the next time you receive an EOB statement, and you’ll be able to understand it like a pro!

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Integrity Now Insurance Brokers help Medicare beneficiaries around the entire United States. No matter how big or small your issue may be, we have the resources you need to solve your problem. 

Do you have questions about your Medicare Advantage plan or Medicare Supplement Plan?  Are you paying too much for your prescription drug coverage?  Reach out to one of our Medicare Agents today,