Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:Introduction to Health Care and Public Health in the U.S.
Unit:Financing Health Care - Part 1
Lecture:Payors in the U.S. Health Care System
Slide content:How Insurers Pay Providers - 2 Patient and provider receive explanation of benefits (EOB), also called remittance advice (RA), from payor Claim can be denied for many reasons: Coding errors Insufficient information Procedure considered experimental or otherwise not covered by the policy Rejected claims can be appealed 8
Slide notes:An explanation of benefits, or EOB, also known as a remittance advice, or RA, is a document issued by the payor stating the status of the claim and whether it is paid, suspended or pending, rejected, or denied. The purpose is to provide detailed payment information relative to the claim and, if applicable, to describe why the total original charges have not been paid in full. If a claim is rejected, the reason must be stated in the explanation of benefits or remittance advice. Claims can be denied because of coding errors or insufficient information, because a service is not covered under the policy, or because a procedure is still considered experimental. Many employer-provided insurance plans have a process for allowing patients to appeal a rejected claim. Under the recent health care reform law, more companies are required to establish this process, as well as allow patients to have a rejected claim reviewed by an independent third party. 8