When you Google, “explanation of benefits,” the first two results are, “what does explanation of benefits mean,” and “how to read an explanation of benefits.” This frequently misunderstood document was actually designed to keep you informed, not create more confusion! Still, many, many adults are bewildered by the statement they receive in the mail stating, “THIS IS NOT A BILL.”
To begin, let’s identify why we have an explanation of benefits (EOB) document in the first place. An EOB is a communication from us (the benefits provider) to the patient or member. It notifies you, (the member) that your provider (dentist) has submitted a claim for services they gave you.
FAQs about EOBs:
- What does explanation of benefits mean?
- Why do I owe you money for the “patient responsibility” if an EOB isn’t a bill?
- I don’t understand what the procedure description is.
- Why didn’t I get an EOB?
- What does “not chargeable to patient” mean?
This document lets both you and Delta Dental know what the dentist wishes to be charged.
It’s our job to hold the provider accountable for their contracted rate. This is the rate the dentist and Delta Dental agreed upon for the dentists’ services. This happens when we bring a new dentist into our network of providers.
If your procedure with your dentist was covered and paid by us at 100%, we won’t send an EOB. That’s because the rate the dentist requested was covered by us.
An EOB is a way for us to keep everyone honest. It allows us to communicate to you, our member, what exactly you are financially responsible for. You shouldn’t ever pay any more or any less than what is stated on the EOB. If your statement says, “not chargeable to patient” anywhere, this is a reflection that the dentist has to “take a write-off,” or they billed above what their contracted rate allows.
You shouldn’t have to take any action when you receive an EOB. That is, unless you:
- Did not have the services listed done,
- Or something looks to be incorrect from what you recall during the treatment.
If you ever feel that there has been an error or something was processed incorrectly, contact us. We’re more than happy to do some research and work through the problem with you!
How to Read an Explanation of Benefits
Once you have it in hand, you’ll want to know how to read a Delta Dental insurance EOB.
On the estimate is a series of columns and numbers. Your “Procedure Code” and “Procedure Description” columns help us and your dentist identify the treatment requested.
The “Submit Amount” and “Fee Adjustment” columns show how much your dentist charged for that treatment. The “Approved Amount” or “Allowed Amount” generally reflects the same number, but may differ based on your coverage.
Since Delta Dental may not cover every treatment your dentist recommends, the “Deductible Applied” column number shows the amount left over that you would be responsible for paying. This payment would contribute to your deductible.
The “Delta Dental Co-Pay” column, also known as “Co-Pay Percent” or “Benefit Level” will reflect the percent of the cost that Delta Dental will cover. This is based on your plans coverage and the doctor’s treatment recommendations. If everything your dentist recommends is covered, this column will reflect “100%.”
Preventive treatments are usually covered at 100%, while basic and major procedures usually aren’t fully covered. That means daily healthy smile habits keep money in your pocket!
What Else Can an EOB Tell Me?
- Coordination of Benefits (COB) information, if applicable
- Portion of annual maximum used and the amount paid toward deductible in the current benefit year.
If you have questions about your EOB or believe that your claim wasn’t resolved properly, contact your plan provider.
Editor’s Note: Content updated October 2018.