Pay your bills and keep any paperwork. Some providers will not 

see you if you have unpaid medical bills. You may be able to go 

online to look up your own health information, such as screening 

and test results or prescribed medications. This can help you take 

charge of managing your health. 

APPEALS AND GRIEVANCES

If you have a complaint or are dissatisfied with a denial of coverage for 

claims under your health plan, you may be able to appeal or file a grievance. For questions about your rights, or assistance, you can contact 

your insurance plan or state Medicaid or CHIP program. If you think you 

were charged for tests or services your coverage is supposed to pay for, 

keep the bill and call the phone number on your insurance card or plan 

documentation right away. Insurance companies have call and support 

centers to help plan members. 

Contact your health plan if you have questions about your EOB. 

Statement date: XXXXXX

Document number: XXXXXXXXXXXXXXXXXX

THIS IS NOT A BILL

Claim Detail What your provider 

can charge you Your responsibility Total Claim Cost

Line 

No.

Date

of Service

Service 

DescriptionClaim 

Status

Provider 

Charges

Allowed 

Charges

CoPayDeductibleCoInsurancePaid by 

Insurer

What 

You 

Owe

Remark

Code

1 3/20/14–

3/20/14

Medical 

care

Paid $31.60 $2.15 $0.00 $0.00 $0.00 $2.15 $0.00 PDC

2 3/20/14–

3/20/14

Medical 

care

Paid $375.00 $118.12 $35.00 $0.00 $0.00 $83.12 $35.00 PDC

Total $406.60 $120.27 $35.00 $0.00 $0.00 $85.27 $35.00

1

5

4 2 3 6 7

Insurance

plan logo

Customer service: 1-800-123-4567

Member name:

Address:

City, State, Zip:

Explanation of Benefits

(EOB)

Subscriber number: XXXXXXXXX ID: XXXXXXXXX Group: ABCDE Group number: XXXXXX

Patient name:

Date received:

Provider:

Payee: Claim number: XXXXXXXXXX

Date paid: XXXXXXXX

Remark Code: PDC—Billed amount is higher than the maximum payment insurance allows. The payment is for the 

allowed amount.

1 Service Description is a 

description of the health care 

services you received, like 

a medical visit, lab tests, or 

screenings. 

2 Provider Charges is the 

amount your provider bills for 

your visit. 

3 Allowed Charges is the 

amount your provider will be 

reimbursed; this may not be the 

same as the Provider Charges. 

4 Paid by Insurer is the amount 

your insurance plan will pay to 

your provider. 

5 Payee is the person who will 

receive any reimbursement for 

over-paying the claim. 

6 What You Owe is the amount 

the patient or insurance plan 

member owes after your 

insurer has paid everything 

else. You may have already paid 

a portion of this amount, and 

payments made directly to your 

provider may not be subtracted 

from this amount.

7 Remark Code is a note from 

the insurance plan that explains 

more about the costs, charges, 

and paid amounts for your visit.

After you visit your provider, you may receive an Explanations of 

Benefits (EOB) from your insurer. This is an overview of the total 

charges for your visit and how much you and your health plan will 

have to pay. An EOB is NOT A BILL and helps to make sure that 

only you and your family are using your coverage. You may get a 

bill separately from the provider. 

Here’s an example of an Explanation of Benefits

Your insurance plan’s or Medicaid or CHIP agency’s Customer 

Service Number may be near the plan’s logo or on the back of 

your EOB .

Reading your Explanation 

of Benefits

Visit go.cms.gov/c2c for more information CMS Product No. 11819

Paid for by the Department of Health & Human Services. Revised July 2018