EOB (explanation of benefits)
DefinitionA readable statement from the payer explaining how a claim was processed: allowed amount, payment, adjustments and what the patient owes.
An EOB is the human-readable version of a claim decision. Two kinds reach a nutrition practice's orbit:
- Provider remittance (paper or PDF): the payer's statement to you, carrying the same group, reason and remark codes as the electronic 835. Medicare's paper version is the standard paper remittance (CMS Claims Processing Manual, Ch. 22).
- Member EOB: what the patient receives. It is not a bill; it tells them how much they may owe you.
How to read one in under a minute:
- Find the line for the date of service and CPT code.
- Compare allowed per unit with your fee schedule.
- Compare units paid with units billed.
- Read every adjustment: the group code (CO, PR, OA) says who absorbs it; the reason code says why.
If you are keying EOBs by hand, enroll for ERAs with that payer so the same data arrives electronically (CMS: Payment and Remittance Advice).