Understanding an explanation of benefits.

1 It's not a bill

Your insurance company sends an explanation of benefits to let you know it got a claim, or a bill, from your doctor or other health care provider. It will show you:

The date of the medical care. What medical services were done. How much the insurance company is paying. How much you might owe.

2 What you may have to pay

If the insurance company doesn't pay the whole amount, the doctor or provider might bill you for the rest. Wait until you get the doctor's bill before paying, and don't pay more than the amount the explanation of benefits says you may owe.

3 What to check

There's no standard format for an explanation of benefits, but there are a few things that you should check:

Make sure the information about you is right. If it’s not, it may be a mistake, or it could be someone trying to use your identity. Make sure you’re not being billed for a service you didn’t get or being billed twice for the same service. If you see a mistake, call the insurance company. Even if the insurance company paid the claim, overbilling is fraud and can lead to higher costs for everyone. Make sure you know which doctor or health care provider sent in the bill. The bill could have the name of the doctor, the group practice, the clinic, a lab, or their billing office. If the insurance company didn't pay anything, check the reason. Does it make sense to you? For example, your insurance might not pay anything if you haven't met your annual deductible.

4 If there's a problem

Contact your health care provider if there's a mistake on the bill. Contact your insurance company if you have a question about what was covered. To learn more about avoiding surprise bills and who to contact if you get one.

If you suspect fraud, call your insurance company. You can also report it to the Texas Department of Insurance through our online form.



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