Example EOB Explanations

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	Example EOB Explanations

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The EOB

The EOB (Explanation of Benefits) is not a bill. After a medical service was rendered, whether by a family or specialty physician, or their staff, specialty clinic, out-patient clinic, emergency room, or hospital a claim is submitted to the patient's primary insurance company.

Billable Services

The patient should receive an EOB from the insurance company four to six weeks after the first claim was filed. The EOB indicates the services that were billed and amounts that were paid to the provider, or denied by the patient's medical insurance company.

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What Are Some Possible EOB Explanations?

Possible EOB Explanations

Explanation of Benefit (EOB) provides important information to the patient. Below are examples of possible EOB code explanations:

1 provider type inconsistent with claim type

2 recipient ineligible for dates of service

3 payment for service included in encounter rate

4 must bill claim using patient mid, not head of household mid

5 your claim was given individual consideration and reimbursed accordingly

6 provider number has not been renewed; contact Electronic Data Systems (EDS) enrollment for assistance

7 please resubmit claim according to new ambulance billing guidelines

8 recipient number missing/invalid/not on file

9 recipient name/number mismatch/missing/invalid

10 recipient ineligible for date of service billed/unknown

11 claim denied; provider name/number on claim doesn't match our files

12 no price on file for revenue code

13 individual charge is missing or not equal to the sum of the details

14 other insurance indicator missing/invalid

15 payment reduced to spenddown amount

16 your claim was reviewed; your coverage was still in effect

17 net charge missing/invalid

18 referring physician information required and not present

19 claim denied; ambulance certification incomplete; please correct and resubmit

20 claim denied; does not warrant ambulance use

21 initial ten (10) ambulance mileage included in base code

22 primary diagnosis missing/invalid

23 pro signature missing

24 anesthesia claim denied; can not pay until submission and pmt of physician claim

25 attending/performing provider number missing or invalid

26 surgical date is missing or invalid

27 2nd surgical procedure date is missing/invalid/illogical

28 3rd surgical procedure date missing/invalid/illogical

29 primary surgical date missing/invalid/illogical

30 provider inactive on date of service

31 please resubmit on appropriate claim form

32 type of bill missing or invalid

33 payment of this detail considered on first line with this date of service billed

34 admission date missing/invalid/illogical

35 the admission date is later than the from and/or through date of service

36 inappropriate code; refer to your current dental list

37 admission code does not warrant emergency room service

38 claim past 365 day timely filing limit

39 second diagnosis not on file or invalid

40 claim denied; attachments are invalid and/or illegible

41 dispensed date or from date of service missing/invalid

42 patient status code is missing/invalid

43 admission code missing/invalid

44 services can't be billed prior to date performed

45 the discharge/through date of service is missing/invalid

46 the through/discharge date of service is missing/invalid

47 NDC is missing or invalid

48 inappropriate procedure code; please refer to your current manual

49 claim denied; procedure code billed must match prior authorization (PA) approval

50 inappropriate billing of multiple procedure codes, please add modifier 51

51 procedure code is not valid for DOS billed

Read: More Example EOBs

How do you read an EOB?

See this interactive Explanation of Benefits!