What Does My EOB Mean?
We'll help you read the insurance statement — no bills to pay here, most of the time.
THIS IS NOT A BILL
An Explanation of Benefits (EOB) is a statement from your insurance company. It shows how they processed a medical claim. You do not send payment in response to an EOB. A separate bill comes from the doctor or hospital — and you only owe what it says under "you may owe." If the bill from the provider is higher than that, something is wrong.
Decode your own EOB — line by line
Type what you see on your statement into the boxes below. We'll translate it, add up what you might actually owe, and tell you whether you should expect a bill later.
Doctor, clinic, or hospital name.
The day you got care.
A 5-digit code like 99213 — we'll decode it.
The charge — often much higher than what anyone pays.
The negotiated "allowed" amount.
What your plan actually sent the provider.
Amount that counts toward your yearly deductible.
Flat fee like $30.
Your percentage share (often 20%).
Or walk through a sample EOB
Click any field to open the "What is this?" plain-English explanation.
Blue Shield of Illinois — Explanation of Benefits
This is not a bill.
Subscriber / Member name
JANE Q DOE
What is this?
Subscriber / Member name
JANE Q DOE
Member ID
XJD123456789
What is this?
Member ID
XJD123456789
Group number
GRP-00487
What is this?
Group number
GRP-00487
Date of service
03/12/2026
What is this?
Date of service
03/12/2026
Provider
DR. SAMUEL REYES, MD — SPRINGFIELD FAMILY MEDICINE
What is this?
Provider
DR. SAMUEL REYES, MD — SPRINGFIELD FAMILY MEDICINE
Claim number
CLM-202603-778214
What is this?
Claim number
CLM-202603-778214
Common CPT procedure codes, decoded
CPT codes are the 5-digit numbers that describe what the doctor actually did. Here are the ones you'll see most often on an EOB.
Office visit — new patient, short
A basic visit with a doctor you have never seen before. Usually 15–29 minutes.
Office visit — new patient, medium
A standard visit with a new doctor. 30–44 minutes. This is common for first-time appointments.
Office visit — new patient, longer
A longer new-patient visit, often for a more complex issue. 45–59 minutes.
Office visit — new patient, long
A complex first visit, 60–74 minutes. Often used for complicated histories or multiple issues.
Office visit — established patient, very short
A brief check-in you had with staff (a nurse visit, blood pressure check, shot). Usually under 10 minutes.
Office visit — established, short
A short follow-up visit with a doctor you have seen before. 10–19 minutes.
Office visit — established, standard
The most common billing code for a regular follow-up visit. 20–29 minutes. If you went in for a cold or a medication refill, this is probably what you got.
Office visit — established, longer
A longer follow-up, usually for two or more concerns or a more complex problem. 30–39 minutes.
Office visit — established, long
A long or complex follow-up, 40–54 minutes. Used for serious or multi-issue visits.
Annual wellness visit — adult, established
A yearly physical for an adult you have been seeing. Preventive — usually 100% covered with no copay on most plans.
Annual wellness visit — senior, established
Annual wellness for patients 65 and older. On Medicare, the first one has a different code (G0438).
Medicare initial wellness visit
Your first "Welcome to Medicare" or Annual Wellness Visit. Free under Medicare if billed correctly.
Medicare annual wellness (subsequent)
The yearly follow-up wellness visit on Medicare. Free if billed as preventive.
Vaccine administration
The fee for giving a shot (not the shot itself — the shot is billed separately).
Flu shot
A standard seasonal flu vaccine. Usually 100% covered.
Tdap (tetanus, diphtheria, pertussis) shot
A tetanus booster, often with whooping cough protection added.
Pneumonia vaccine
A pneumonia shot (Pneumovax). Often free for seniors under Medicare.
Chest X-ray, single view
A basic chest X-ray — one image.
Chest X-ray, two views
A chest X-ray with two pictures (front and side).
General health panel (blood work)
A broad blood test that includes chemistry, blood cell counts, and thyroid.
Comprehensive metabolic panel
A common blood test that checks kidney function, liver function, blood sugar, and electrolytes.
Hemoglobin A1C
A blood test that measures your average blood sugar over the last 3 months — for diabetes management.
Complete Blood Count (CBC) with differential
The standard blood count — red cells, white cells, platelets. Very common.
Blood draw
The act of drawing blood (the needle stick). Billed on top of the actual lab tests.
Electrocardiogram (EKG)
A heart rhythm test — the sticky patches and paper printout.
Flu shot administration (Medicare)
The fee for giving the flu shot on a Medicare plan. Free when billed correctly.
Screening mammogram
A routine breast cancer screening. Free under most plans once a year after age 40.
Colonoscopy, diagnostic
A colonoscopy performed to check on symptoms. Different code than a pure screening (which should be free).
Screening colonoscopy (Medicare)
A preventive screening colonoscopy on Medicare. No copay or coinsurance if billed this way — if you are charged, ask them to re-bill.
Physical therapy — therapeutic exercise
15 minutes of supervised exercises with a physical therapist. Often one visit has 3–4 of these stacked.
Status / adjustment codes
Your EOB uses short codes to explain why each dollar amount was adjusted. Here are the ones you'll see most.
Patient Responsibility
You owe this part (deductible, copay, or coinsurance).
Contractual Obligation
Written off because of the network contract. You do NOT pay this — and neither does the plan.
Other Adjustment
Reduced for some other reason (duplicate, coordination of benefits, etc.).
Payer Initiated Reduction
Insurance reduced it for a non-contractual reason.
Deductible amount
Applied to your yearly deductible.
Coinsurance amount
Your percentage share.
Copayment amount
Your flat copay.
Charge exceeds fee schedule
Provider charged more than the negotiated rate — you do not pay the difference in network.
Non-covered charge
Your plan does not cover this service. You may owe it — but ask if an appeal or coding fix is possible.
Precertification / authorization not obtained
Often appealable — the provider may not have filed the right paperwork.
Red flags — signs of a billing error or fraud
If you see any of these, stop and investigate before you pay anything.
- •Services you don't remember receiving. Even if it's a small lab fee — if you didn't get it, it shouldn't be on your EOB.
- •Amounts wildly different from what you expected. A $30 office visit suddenly billed at $800 is worth a phone call.
- •A provider name you don't recognize. Sometimes the billing name is the practice or a lab, not the person you saw — but always confirm.
- •Balance billing over the insurance-approved amount. If an in-network provider tries to bill you more than the "you may owe" line, that may be illegal under your plan's contract and the No Surprises Act.
- •The same service charged twice on the same day — classic duplicate billing error.
- •A date of service that doesn't match your actual visit.
- •Out-of-network when you confirmed in-network. Appeal under the "No Surprises Act."
See something suspicious? Report it.
Medicare fraud costs taxpayers billions every year. If a service on your EOB looks wrong and the provider won't fix it, you can report it in minutes.
Medicare.gov/fraud
Report Medicare fraud online. Works for Medicare Parts A, B, C, and D.
1-800-MEDICARE
(1-800-633-4227) — Call 24/7. Tell them you want to report suspected fraud and have your Medicare number ready.
For private insurance, call the fraud line on the back of your insurance card instead.
Common situations
Rule of thumb
Never pay a medical bill until you see the matching EOB. Line up both pieces of paper. The "you may owe" number on the EOB is the ceiling. You rarely owe the full "billed amount" — and you never owe the "contractual adjustment" if the provider is in network.
See your official Medicare claims
If you're on Medicare, you can see every claim ever filed on your behalf — and download your Medicare Summary Notices (the Medicare version of an EOB) — directly from the official website.
Open Medicare.gov/claimsBefore you hang up with insurance, always ask:
- • "Can you give me the call reference number?"
- • "What is the appeal deadline for this claim?"
- • "What's the exact reason code on this line?"
- • "Can you email or mail me a written confirmation of this conversation?"
- • "What's the name of the rep I'm speaking to?"