• Sarah Beth Herman

Understanding EOB's



Part 2: Understanding EOBs (A little bit on appeals too!)

What is an EOB?

EOB: Explanation of Benefits.


EOB does not mean dental claim. An EOB is similar to a receipt you may receive from a contractor. If you complete services for a patient you receive an EOB and a check for payment. While I wish there was a one size fits all EOB, this just is not the case. All EOBs are different and reflect different ways insurances factor their payment and deductions from payments made to a rendering provider. We are going to look deeper into this in just a moment.


Simply put, your EOB is an important record of your office's dental services rendered for a patient.


Five Main Things You'll find on an EOB:

  1. Claim information (what was submitted by the dental office?)

  2. Service and coverage information (the benefit of the patient's dental insurance plan)

  3. Explanation (was the claim paid? Details about the payment or denial)

  4. Patient identifiable information such as policy number, group number, and date of birth)

  5. Details on resubmissions needed (if applicable)

How should you store an EOB? How long should you keep them? What do I do if my front office accidentally deleted it or forgot to upload it?


First, always reach out to your state/local dental association for their requirements. This can vary by state. Second, insurance companies are required to keep these on file as records of payment for 7-10 years depending on their local rules and regulations.


Ok, let's get to the good stuff.


Scan EOBs into the patient's chart electronically, but if you have older dental software or an older computer this could bog down your server. It may be easier to store them in a file on your desktop by the date you posted the payment or closed the claim. Our biggest advice is DO NOT store paper copies. Now, if you want to, that is up to you but that MUST be locked on its own within your office.

How do I properly bill for an associate doctor who is not credentialed yet?


I see offices overcomplicate this all the time. It's simple.


Always use the current and most recent version of the ADA Dental Claim form. There is a space for the location and rendering provider. If they are out of network, it will be paid out of network even if the office is in-network and according to those terms set forth by the dental insurance company. Credentialing must be done for any provider to whom you are seeking in-network benefits to be paid out.

Why did the insurance pay less on the EOB than what we have written on the Breakdown of benefit?


Most common reason: The office is not a participating provider or the insurance company needs updated credentialing information.


If that is not the case, check the EOB for accuracy and resubmit with updated information along with a letter explaining why it was initially submitted in error.

What is the formula for calculating the patient portion with a deductible?


Fee - deductible x patient out of pocket % + deductible = patient portion




Example:

$1,000 crown

$50.00

80% coverage by the insurance and 20% patient portion


Let's solve the problem:


$1,000 - $50 = $950.00 x .20 = $190.00 + $50.00 = $240.00 total patient cost.

7 steps to appeal

  1. Know the rules from the insurance company. Every insurance company is different and you want to follow the rules for how to send (electronic/snail mail) an appeal and submit for one.

  2. Always write a separate letter, Do not try to add notes to a claim. It will likely NOT be read and you will be reappealing.

  3. What should you write:

Office Name

Office Address

Office Phone Number

Office Email Address (They may email you updates)


Patient Full Name

Patient Address

Patient Phone Number

Patient Date of Birth

Patient/Member ID

Claim Number

Reference Number


4. Use Clinical Notes. But give them sterroids. Add more information and make it worthy of reading. (Check out our narratives that can be added to your clinical notes.)


5. Attachments, send them again but give them sterioids. Add perio charting and intra oral photos. Do everything you can to give the most information possible. Seek out final reports from specialty dentists if you referred the patient out.


6. Change your words. If the dental insurance company said the initial claim is denied, you have to change it up. We want to avoid using any of the same nomenclature from the initial claim. Using the same verbage = the same denial.

7. Notify the patient the claim has to be appealed and ask them for help. The member calling the insurance is a BIG DEAL.

Appeal Letter Template:


Office Name

Office Address

Office Phone Number

Office Email Address (They may email you updates)


Patient Full Name

Patient Address

Patient Phone Number

Patient Date of Birth

Patient/Member ID

Claim Number

Reference Number


Attachments: [List all attachments included with the letter]


This is the [# of appeal] appeal submitted by the request of [patient name].


[Dental Office Name] has received a denial dated [date].


You have been provided sufficient proof [patient name] required [list treatment and tooth numbers]. Despite this medical and dental neccssity you have denied the claim due to [reason stated in denial].


The [list the treatment and tooth numbers] are necessary due [list narrative/clinical note reason here].


[Insert Doctors name] expressly requests you to consider the health and dental wellness of [patient name]. [Insert Doctors name] diagnosed and determined a need for this treatment.

The standard of care for a patient with this condition is [insert treatment and tooth number rendered]. [Insert Doctors name] asks you to review the evidence provided and allow our patient the benfits they are rightly owed and qualified to receive.


Common Definitions on EOBs:

(Not all are listed from every insurance company, these are the most common)


TH: Tooth Number

SURF: Surfaces of the tooth treated (if applicable)

Service Date or Date of Service: The date the patient was seen for the services they received in the dental office.

Procedure Code: ADA code submitted by the dental office to define the service the patient received.

Submitted Amount: The fee amount attached to the ADA code submitted by the dental office.

Approved Amount: Depending on network status this is the maximum allowed amount the office can charge for the service. The dental insurance company will not pay on any amount exceeding.

% Copay or Payment Level %: The dollar amount or percentage your dental insurance plan will cover per procedure.

Contract Allowed or Allowed Amount: This amount depends on your employer's contract with Delta Dental, as some employers may place a dollar limit on certain procedures. In most cases, the approved amount and allowed amount will be the same.

Coinsurance:

The percentage above the allowance that is patient responsibility.

Reference Code, Adjustment Notice, or Process Policies: Explains any limitation on your insurance coverage for the procedure you received.

Procedure Description: Describes the treatments and procedures the patient has received at the dentist’s office.

Fee Adjustment: The difference between the approved amount and the submitted amount.

Claim Number: The number assigned to the claim that corresponds to the EOB.

Other Insurance Paid: The amount paid by any other insurance a patient may have.

Benefit Period: The period of time of a patient's coverage.

Annual Maximum: The maximum dollar amount dental insurance will pay toward the cost of dental services and treatment. Tip: This is not the most a patient will pay out of pocket per year that is seen in medical insurance plans.

Annual Maximum Used to Date: The amount of the patients plan maximum used to date during a benefit period.

Overmax: The amount which exceeds the patients plan maximum during a given benefit period.

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