The explanation of benefits (EOB) explains the costs for services you received. This includes what the provider billed for, what Highmark paid for, and what you will need to pay. When you get a bill, you can compare it to the EOB to make sure everything looks correct. It's a summary of the charges and payments related to your medical care. Itʼs not a bill. We provide this summary to help you understand how your plan covered the services you received, according to your benefits.
You can see how much we have paid and how much you have or can expect to pay.
If you owe anything, your doctors and other healthcare providers will send you a bill
Explanation of benefits
Members get an EOB after we process certain types of claims. An EOB might include:
Member ID number
What you owe the provider
Information about your coinsurance, copay and your deductible
The amount for health care services that are not covered by your plan.
The amount you’ll pay for the service or procedure.
The amount your provider charged for a service to your health plan. This is the total price for the service or procedure before insurance is applied. It’s the amount you would be billed if you didn’t have insurance.
This is the price for the service after your insurance was applied. Your plan negotiated with your provider to give you a discounted rate.
A fixed dollar amount that you pay upfront each time you receive covered health care services. Copays can vary based on the service, such as seeing your primary care provider or visiting a specialist.
The set amount you pay for covered health services or drug costs before your plan starts paying.
The percentage you may owe for certain covered services after reaching your deductible. For example, you pay 20%, your plan pays 80%.
The provider will bill you for this amount.
Log in to your member account to view your EOB. If you're having trouble logging in to your member account, we can help.
Log in to your member account to choose to have your EOB emailed to you.
The amount your plan covered for health care services.
The request for payment thatʼs sent to your insurance company after you receive covered care.
When a provider bills you for the difference between the providerʼs charge and planʼs allowed amount. Providers may not balance bill you for covered services if they are In-Network or for Medicare Advantage plans the provider is a Medicare participating provider.
The most youʼd pay for covered services within a plan year. If you reach this amount, your plan pays 100% of covered services after that.
The amount you will have to pay in a plan year. The maximum out-of-pocket always includes coinsurance, and may include copayments or deductibles. For some plans prescription drug expenses don’t count towards the maximum out-of-pocket.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies. This website is operated by Highmark, Inc. and is not the Health Insurance Marketplace website. It also does not display all Qualified Health Plans available through the Health Insurance Marketplace website. To see all available Qualified Health Plan options, go to the Health Insurance Marketplace website at HealthCare.gov.
Highmark Blue Cross Blue Shield or Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal. ®Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Benefits and/or benefit administration may be provided by or through the following entities, which are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Visit our website to view the Access Plan required by the Health Benefit Plan Network Access and Adequacy Act. You may also request a copy by contacting us at the number on the back of your ID card. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
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