After visiting a doctor’s office, it might be confusing for most students to understand what to do when you receive an explanation of benefits (EOB). Usually, if you go to an in-network doctor’s office, the office should be able to file a claim for you. If you visit out of network, you can always file a claim by following the steps here.
What is a claim? What happens after the visit?
A claim is a request for payment from the doctor’s office, hospital, or clinic to the insurance company after your visit. This bill is sent to SISCO Benefits for processing and will generally take 10-20 business days. Once your claim has completed processing, you and your doctor’s office will receive an explanation of benefits in the mail.
What is an explanation of benefits (EOB)?
An EOB will provide you a breakdown of health insurance coverage for your doctor’s visit and will tell you what is covered and what is your responsibility for the bill. This document is not a bill. Any patient responsibility indicated on the EOB will need to be paid directly to your doctor’s office.
Your EOB will help you answer the following questions:
- How much did insurance cover?
- What went towards the deductible?
- How much discount you have received?
- How much do I need to pay?
- Are additional documents needed to process the claim?
Get a refresher on insurance terms here.
How to read an EOB
- Dates of Service: the date you visited the doctor’s office or received treatment.
- Procedure Code: a code for the service you received during the visit. You can view “Services Code” for more information.
- Total Charge: the total amount charged for the visit.
- Discount Amount: applies when you are visiting in-network. This is the negotiated rate or savings you received and will be deducted from the “Total Charge” amount.
- Ineligible Amount: amount not covered by insurance
- Reason Code: the reason why the service was listed as ineligible or discounted. You can view the remark code section for more information.
- Allowed Amount: this is the total charge minus the discount amount
- Copay Amount: the amount that is applied to the copay
- Deductible Amount: amount applied to your deductible
- Claim Detail: this is the ‘Total Amount’ – ‘Discount’ – ‘Copay’ – ‘Deductible’ = ‘Remaining Balance’. Then the coinsurance is applied to the ‘Remaining Balance’ providing you the amount insurance covered under ‘Plan Payment Amount’. For the portion insurance covered, the payment will be made directly to your provider’s office.
- Patient Responsibility: the total amount you need to pay to your doctor’s office after insurance coverage. Payment for this portion should also go directly to your provider’s office, not to ISO or SISCO Benefits. You should expect to receive a bill from your doctor’s office for the amount listed here. If the amounts do not match, you should contact your provider for more information.
For more information on EOB documents, you can view here.
Remark Codes you should pay attention to:
These remark codes mean that you will need to submit additional information to have your claim processed. Make sure to submit this information in a timely manner to prevent delays in processing your claim. You should view the second page of your EOB and complete the information required here. Once complete, submit to SISCO Benefits directly at ISOservice@siscobenefits.com.
Where can I access my EOB?
- Mailed to you: A copy of your EOB will be mailed to the address on file, so ensure you have entered an updated address on your ISO account.
- SISCO Benefits Account: view claim status and EOB 24/7 through your web account.
If you have any other questions regarding how your claim was processed, reach out to our claims department, SISCO Benefits, at (833) 577-2586, or email ISOservice@siscobenefits.com.
