When you use your Blue Shield medical plan benefits, such as when you see a doctor or have lab work done, and a claim is submitted to Blue Shield, we are legally required to send you an Explanation of Benefits (EOB). It shows that a claim was processed and explains the cost of your care, what was covered by Blue Shield, and what is your responsibility. The EOB is not a bill.
How do I read an EOB?
Making sense of your EOB may feel complicated, but it doesn’t have to. We’ll walk you through it.
The EOB has two sections: “Claims summary at a glance” and “Detail.” The guide below breaks each one down. See the highlighted letters and their corresponding descriptions in the charts that follow. Pay special attention to letters A, M, N, and O, as they include amounts that you are responsible to pay the provider. Then be sure to explore the FAQs below.
Section 1: Claims at a glance
| Name | Description | |
|---|---|---|
| A | Patient responsibility | The total amount you’re responsible to pay the provider. It consists of your deductible, your copayment/coinsurance, and any non-covered amounts. |
| B | Blue Shield responsibility | The total amount Blue Shield paid to the provider (if the provider filed the claim) or to you (if you filed the claim). |
| C | Network savings | The amount you saved by using a provider in your plan’s network. |
| D | Amount billed | The amount your provider billed for the services. |
| E | Deductible status | The total amount applied toward your annual deductible so far this year. Once you have paid the full deductible amount, Blue Shield will begin paying benefits under your plan for covered services. |
Section 2: Detail
| Name | Description | |
|---|---|---|
| F | Provider | The name of the doctor, hospital, or other healthcare professional that provided the services. |
| G | Preferred provider | The providers’ network status: “Yes” means the provider is in network, while “No” shows the provider is out of network. Usually, your cost share is lower for covered services from in-network providers. |
| H | Service date | The day or date the patient received the services. |
| I | Type of service | The name and code for the services. |
| J | Amount billed | The amount the provider billed for the services. |
| K | Amount allowed | The amount covered (allowed) for each service according to your plan. |
| L | Amount we paid | The amount Blue Shield paid to the provider or to you for each service. |
| M | Not covered | The portion of the amount billed that was not covered by your plan. You are responsible for this amount. |
| N | Deductible | The amount you owe the provider for the service that will count toward meeting your deductible. You are responsible for this amount. |
| O | Copayment/coinsurance | The amount (copayment) or percentage of cost (coinsurance) set by your plan benefits for this service. You are responsible for this amount. |
| P | Notes | Additional comments about the claim. |
EOB Frequently Asked Questions (FAQs)
Can I opt out of receiving EOBs?
No, Blue Shield is legally required to send an EOB for each claim that we process.
Can I get my EOBs electronically?
Yes, you can have digital EOBs delivered via the Blue Shield app or your online member account. To do so, log in to your account, select “My profile,” scroll down to “Communication preferences,” and in the “Know your medical plan” section, select “electronic delivery.”
Why didn’t I receive an EOB?
If you are enrolled in an HMO plan, some services – such as physician office visits – are processed directly by your primary care physician’s medical group (IPA) rather than by Blue Shield. If this is the case, you will not get an EOB from Blue Shield. Your member responsibility for all claims can be viewed by logging in to your account and looking under the “Claims” tab, or by calling customer service.
Why did I receive more than one EOB?
Many treatments involve more than one provider, such as a surgical procedure that involves billing from the surgeon, operating facility, anesthesiologist, and lab. Each entity providing services may bill separately.
Why does my EOB look different from the one above?
There are some Blue Shield EOBs that look a little different from the example shown here. We will be happy to walk you through any Blue Shield EOB you receive. Give us a call at the number on your Blue Shield member ID card.
What is “preferred provider” versus “non-preferred provider”?
A preferred provider (also known as in-network provider or participating provider) has entered into an agreement with Blue Shield of California to accept our allowed amount as payment in full. This gives you the highest level of benefits. You are only responsible to pay any applicable deductible and copayment/coinsurance. Blue Shield pays these providers directly. The "Network savings" box on your EOB shows what you saved by using preferred providers.
A non-preferred provider (also known as out-of-network provider or non-participating provider) has no agreement with Blue Shield of California, resulting in a lower level of benefits. You are responsible for any applicable deductible and co-payment/coinsurance, plus any remaining difference between the billed amount and our allowed amount. Blue Shield does not pay non-preferred providers directly; any payment issued by Blue Shield is mailed to the member.
To receive the highest level of benefits and reduce your costs, it’s best to use a provider that is in your network. You can explore your options using Find a doctor.
Why is my network savings $0?
If you receive services from a non-preferred provider or have another health plan as your primary coverage, your network savings will be $0. You will see network savings when you use preferred providers for covered services and your primary health plan or insurance coverage is with Blue Shield of California.
What is the difference between “billed amount” and “allowed amount”?
The billed amount is the amount charged by your physician, hospital, or other provider(s) for the service(s). The allowed amount is determined by Blue Shield, based on contractual agreements with preferred providers or based on the individual procedure billed within a geographical region.
Preferred providers have agreed to accept Blue Shield’s allowed amount as payment in full. Any difference between the billed and allowed amount is reflected as your network savings. You will only be responsible for any applicable deductible and copayment/coinsurance.
If you receive services from a non-preferred provider, you are responsible for the difference between the billed and allowed amounts, in addition to any deductible and copayment/coinsurance.
What should I do if I believe there is an error on an EOB?
A good first step is to call Blue Shield at the number on your Blue Shield member ID card. Our customer service team will be happy to review the EOB with you.
How can I find out more about my deductibles and out-of-pocket maximums?
You can find this information by logging in to your online account, clicking on the “Benefits” tab and looking under “Benefit Maximums.”
What should I do if I have more questions?
Please call us at the number on your Blue Shield member ID card. We’re here to answer your questions and put you at the center of everything we do.
