Your explanation of benefits

What’s an explanation of benefits and why is it important?

An explanation of benefits, or EOB, is a statement you get from your health plan to let you know a claim was paid and processed. An explanation of benefits is not a bill.

An EOB shows the total cost of health care services you received:

How much your health plan covers
What you’ll pay your provider, if you owe anything — your provider will send you a bill

EOBs are important documents that can also help you track your out-of-pocket costs for the year .

We provide two types of EOB statements in your Sharp Health Plan online account.

Summary EOB See sample	Individual EOB See sample
Shows your health care service claims for a one-month period	Shows more detail for health care service costs, such as copay and coinsurance
Shows data we received that month from providers and medical groups	We pay our share of costs to providers weekly
Shows claims we paid and processed that month	An individual EOB will show up in your online account if we paid and processed a claim to your provider that week
California law requires us to mail these to you for each month you access care	You won't get these in the mail. These are only available in your online account
You can choose paperless EOB statements in your online account

Sample Summary EOB Page 1

EOB statements show information for one person. Page 1 lists the person’s name and member ID#.

If other people are enrolled in your benefit plan, like a spouse or child, you may get multiple EOBs each month.

Page 1 of the Sample Summary EOB from Sharp Health Plan

Sample Summary EOB Page 2

Next, you’ll see the maximum out-of-pocket limits and deductibles that are part of your benefit plan. It includes your plan’s effective date range, out-of-pocket costs and out-of-pocket maximum for covered services.

Page 2 of the Sample Summary EOB from Sharp Health Plan

Sample Summary EOB Page 3

Claim information shows your claim reference number, date of service, provider, location and payee. This section also has a summary of your totals, including how much your provider billed us, how much we paid and your share of the cost, if applicable.

Page 3 of the Sample Summary EOB from Sharp Health Plan

Sample Summary EOB Page 4

Service details include your claim’s service, any related codes, date of service, how much your provider billed us, how much we paid and your share of the cost, if applicable.

Page 4 of the Sample Summary EOB from Sharp Health Plan

Sample Individual EOB Page 1

EOB statements show information for one person. Page 1 lists the person’s name and member ID#.

Page 1 of the Sample Individual EOB from Sharp Health Plan

Sample Individual EOB Page 2

The maximum out-of-pocket limits and deductibles, if any, of your benefit plan are shown as progress bars.

Page 2 of the Sample Individual EOB from Sharp Health Plan

Sample Individual EOB Page 3

Claim information shows your claim reference number, date of service, provider, location and payee. This section also has a table with the total cost of services, in plan savings , the amount covered by your plan and the total expected cost.

Service details give a breakdown of what the procedure costs between us. See definitions for key terms used.

Allowed: The maximum amount we pay for covered health care services.
Copay: A fixed amount you pay for a covered health care service after you’ve paid your deductible, if applicable.
Deductible: The amount you pay for covered health care services before we start to pay. If your benefit plan does not include a deductible, the deductible will be listed as zero on your EOB.
Coinsurance: The percentage of costs of a covered health care service you pay after you’ve paid your deductible, if applicable.