Explanation of Benefits

Every health insurer, including HMOs, is required to provide the insured or subscriber with an Explanation of Benefits (EOB) form in response to the filing of a claim.  EOBs are not required when the service is provided by a participating provider who receives full reimbursement directly from the insurer.  However, EOBs will be provided upon request.

The EOB must include at least the following:

1. Name of the provider of service.
   
   
2. Date of service.
   
   
3. Identifcation of the service.
   
   
4. Provider's charge.
   
   
5. The amount or percentage payable after deductibles, co-payment and any other reduction of the amount claimed.
   
   
6. An explanation of any denial, reduction, or any other reason for not providing full reimbursement for the amount claimed.
   
   
7. Telephone number or address where an insured may obtain clarification.
   
   
8. Information on how to file an appeal of a denial of benefits including the applicable timeframes to file.
   

Best viewed in Internet Explorer 6.0.

Sponsored by the New York State Insurance Department
www.ins.state.ny.us
© 2008