Understanding Explanation of Benefits

Knowing What You Pay For

Visiting the doctor can be a stressful experience. Whether you scheduled an appointment because of an ailment, or you are there for a wellness-check, the doctor’s office tends to make people feel vulnerable. With changing healthcare regulations and insurance policies, understanding the costs related to visiting the doctor can help ease some of the burden.

The Basics

When you visit the doctor, depending on the type of insurance policy you carry, you may be asked for a copay. This is usually required when you check-in for your appointment. After your appointment is over, the practice will collect payment from your insurance company, and then bill you for the amount your insurance doesn’t cover.

Your explanation of Benefits

As a patient, you will receive an explanation of benefits (EOB) after your insurance has been billed. This will outline the services and costs your insurance company paid for, and the amount that you are responsible to pay for. An EOB can be difficult to understand, but there are a few things you should check to make sure you are billed correctly. While little things on an EOB may not seem like a big deal, mistakes in addresses, location of services, or services performed can cause your insurance company to reject the claim or take extra time to process.

Important Explanation of Benefits Terms


Enrollee Name – the name of the policy holder, not necessarily the patient

Patient – the name of the person who received services

Provider Name – the name of the doctor or practice that administered services

Claim Number – the number assigned to the claim by your insurance company

Enrollee Address – the address of the policy holder

Date of Service – when the services were rendered

Place of Service – the location where the patient received services

CPT Code – a universal code that identifies the service performed

Charge Amount – amount charged by the provider

Allowed Amount – amount previously determined for the cost of services

Not Covered – cost beyond the allowed amount, usually to be paid by the patient

Reason Code – an explanation of why a service has been denied

Deductible – the amount a patient must pay before the insurance company pays

Benefit Amount – percentage at which the amount covered will be paid by the insurance company

Due from Patient – the amount the patient is responsible to pay


The Smile Institute is a proud network provider of the Delta Dental networks, Moda, Cigna and Washington Dental services. For information on OTHER INSURANCES we accept, please call our office.


explanation of benefits