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Explanation of Benefits (EOB)

What your EOB can tell you

An Explanation of Benefits (EOB) gives you details about health care services you recently received. It details what you may owe or how much you may have paid for the service. EOBs are not bills.

We know EOBs can be confusing. That’s why we’ve designed ours to be easier to understand. Watch the video below and review our quick guide (PDF) | Tutorial de la Explicación de Beneficios (PDF) to learn about your new EOB.

I received both an EOB and a bill. What is the difference?

  • EOBs provide an overview of the medical services you’ve received. They outline what you owe or may have paid your provider. When you receive an EOB, there is no expectation for you to take action, such as making a payment. However, your EOB will tell you what you can do if something looks wrong.
  • Receiving a bill means that you have a balance that you need to pay to your provider. UPMC Health Plan will not send you bills for medical services you’ve received.
    • If you received medical care from a UPMC provider, you can use our self-service resources to learn how to pay your bill.

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Once you update your preference, we’ll send you an email to confirm you’ll receive your future EOBs digitally. You can change your preference at any time and go back to receiving a paper copy in the mail.

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Have questions? Check out some of the frequently asked questions below to see if we have an answer for you!

  • What is a deductible?
    • This is the amount you must pay for covered health care services before your insurance plan will start to pay. For example, if you have a $2,000 deductible, you must pay the first $2,000 for covered services.
  • What is coinsurance?
    • Coinsurance is the percentage of the cost of your covered health care services that you must pay after you've paid your deductible.
  • Why am I seeing a claim denial on my EOB?
    • There are reasons why a claim may show as denied on your EOB. A few examples are that the service was not deemed medically necessary, the service was not appropriate for the specific health care setting or level of care, or the effectiveness of the medical treatment has not been proven.
  • What does it mean if a doctor is out of my network?
    • A provider who isn't contracted with your insurance company is referred to as “out-of-network.” This means that the provider does not have an agreement with your insurance company to receive payments at a negotiated rate. That provider will likely not be covered under your plan.
  • How can my EOB help me?
    • It will show you which services your insurance covered, why a claim may have been denied, in-network versus out-of-network prices, and more.