Insurance Terms: Billing Services
Understanding the Explanation of Benefits (EOB) received from your insurance company.
An EOB is a document sent by insurance companies that explains how a claim was processed. Generally, it indicates what was paid and/or what was denied. Most insurance companies use their own format for EOBs. The following table lists some common language and information found on EOBs.
Term | Description |
Amount Paid | The portion of the total bill that has been paid by the insurance company. |
Allowed Charges | The amount the insurance company approved for processing. |
Capitation Accounts | These are clients (HMOs, IPAs, physicians, etc.) who generally pay a fixed rate based on a number of members per month and/or volume of tests. Capitated clients usually provide services for HMOs. |
Claim Number | The number assigned by an insurance company to a particular patients bill; this number is often provided on the insurance companys response to Quest Diagnostics. |
Coinsurance | The portion of the allowed charges (usually a certain percentage) that is the patients responsibility. |
Contract Charges | The portion of the total bill that is NOT owed to Quest Diagnostics (by the insurance company and/or the patient); this amount is based on the contractual agreement between the insurance company and Quest Diagnostics. |
Coordination of Benefits | Indicates the amount owed by another insurance company when the patient has additional insurance coverage. |
Copay | The amount required to be paid by the patient. |
Date of Service | The date on which the laboratory testing was performed. |
Deductible | A specific annual dollar amount that must be paid by the patient before the patients insurance will begin reimbursing for covered services. |
Excess over UCR | The portion of the total charges that is greater than the allowed charges; this amount is based on the contractual agreement between the insurance company and Quest. "UCR" stands for usual, customary and reasonable. |
Explanation of Payment | The section of an EOB that details how payments were made and explains any payment codes used. |
IPA | Independent Practice Association |
Non-covered | A specific service that is excluded from a contract and is considered non-payable by an insurance company. The patient may be responsible for this amount. |
Patient Information | Various information including patient name, patient Id number, responsible party, subscriber, insureds name, employees group number. |
Patient Responsibility | Amount patient owes provider (Quest Diagnostics). This includes "not covered" amounts,"deductible amounts," and any percentage of balance, if payment is less than 100%.Note: Although copays are not a part of this calculation, they are also the patients responsibility. |
Provider Information | Payee (Quest Diagnostics) name and mailing address. Additionally, may include account number on the claim, provider number and the name of the provider. |
Service Code | A code representing the service provided. |
Submitted Charges | The amount Quest Diagnostics billed for service provided. |
Units | The number of items included in this service. |
UCR | Stands for usual, customary and reasonable and refers to fees for services. |