The explanation of benefits (EOB) explains the costs for services you received. This includes what the provider billed for, what Highmark paid for, and what you will need to pay. When you get a bill, you can compare it to the EOB to make sure everything looks correct. It's a summary of the charges and payments related to your medical care. Itʼs not a bill. We provide this summary to help you understand how your plan covered the services you received, according to your benefits.
Explanation of benefits
Members get an EOB after we process certain types of claims. An EOB might include:
The amount for health care services that are not covered by your plan.
The amount you’ll pay for the service or procedure.
The amount your provider charged for a service to your health plan. This is the total price for the service or procedure before insurance is applied. It’s the amount you would be billed if you didn’t have insurance.
This is the price for the service after your insurance was applied. Your plan negotiated with your provider to give you a discounted rate.
A fixed dollar amount that you pay upfront each time you receive covered health care services. Copays can vary based on the service, such as seeing your primary care provider or visiting a specialist.
The set amount you pay for covered health services or drug costs before your plan starts paying.
The percentage you may owe for certain covered services after reaching your deductible. For example, you pay 20%, your plan pays 80%.
The provider will bill you for this amount.
Log in to your member account to view your EOB. If you're having trouble logging in to your member accountopens a new tab or window, we can help.
Log in to your member accountopens a new tab or window to choose to have your EOB emailed to you.
The amount your plan covered for health care services.
The request for payment thatʼs sent to your insurance company after you receive covered care.
When a provider bills you for the difference between the providerʼs charge and planʼs allowed amount. Providers may not balance bill you for covered services if they are In-Network or for Medicare Advantage plans the provider is a Medicare participating provider.
The most youʼd pay for covered services within a plan year. If you reach this amount, your plan pays 100% of covered services after that.
The amount you will have to pay in a plan year. The maximum out-of-pocket always includes coinsurance, and may include copayments or deductibles. For some plans prescription drug expenses don’t count towards the maximum out-of-pocket.
