Understanding Your Explanation of Benefits

An Explanation of Benefits (EOB) is a document that summarizes your care, coverage and costs for medical and dental services—it is NOT a bill. To better understand how to read your EOB, take our brief tour.

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Total Provider Charges, Allowed Charge, CareFirst Member Discount

DISCLAIMER—The information contained in this sample EOB is for illustrative purposes only. It is meant to highlight recent design improvements. The details contained in your actual EOBs will differ.

Access Your EOBs Online & Go Paperless With My Account

Register for our secure website, My Account, to view your EOBs online anytime.
Once registered, follow these steps to go paperless.

In My Account, click your name in the top right corner and select Communication Preferences from the drop-down menu.

Select Edit, located next to the Electronic Communication option.

Check the Email box in the Explanation of Benefits (EOB) row and save your changes.

Go Paperless

Frequently Asked Questions

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About EOBs

Why are EOBs important?

EOBs ARE IMPORTANT FOR SEVERAL REASONS

To ensure the services you received and the providers listed are accurate.

To identify any inconsistencies when you get the actual bill.

To request a payment plan from the provider or find other payment options if you think a bill will be difficult to pay.

To include as documentation if you appeal an insurance decision, dispute a charge, or file your year-end taxes.

What is an electronic Explanation of Benefits (eEOB)?

An electronic Explanation of Benefits (eEOB) has the same information as a paper EOB, but it can be viewed on your computer or mobile device. Like paper EOBs, electronic EOBs summarize medical and dental claims processed by CareFirst for you, your spouse and dependents (if applicable).

You may visit My Account anytime to change your email notification preference. If you choose not to receive email notifications, you will begin to receive EOBs via the U.S. Postal Service.

How do I access my eEOB?

If you are a registered user of My Account, you can log in and visit the EOB section of the site under Claims. You can access an eEOB in My Account as often as you’d like. Only the registered subscriber can access eEOBs through.

eEOBs can be viewed and printed at your convenience. Once available, eEOBs will be accessible online for as long as three years. Any eEOBs created before you registered for My Account will not be available.

To print a copy of your eEOB from My Account:

Click Claims in the top menu and select View My Explanation of Benefits (EOB).
Locate the eEOB you’d like to print and click on the Open Printable EOB PDF link.

Understanding Your EOB/eEOB

Why doesn’t my Total Provider Charges graph have three colors?

HERE ARE SOME EXAMPLES OF WHEN THAT MIGHT HAPPEN:

You saw an in-network provider and CareFirst is covering your total cost.

Since the amount you owe is $0, there is no orange portion to the graph.

Your claim was denied, but the provider is liable.

Here, you owe nothing, but neither does CareFirst. The provider is covering the cost.

Your claim was processed as out-of-network and you are liable for the entire bill.

In this case, you must pay the provider’s full charge for service. Depending on your health plan, CareFirst may reimburse you for part or all of the charge.

Where can I find the procedure codes to learn which services were performed?

There are two ways you can request procedure codes.

Call your provider’s office.
Call Customer Service on the back of your member ID card and request a letter be mailed to you with that information.

I can't view my eEOB in My Account. What can I do to resolve this?

STEPS TO ADDRESS THIS ISSUE INCLUDE:

Clearing your cache

Disabling pop-up blockers

Closing and reopening your browser

If the problem persists, call the Customer Service number on the back of your member ID card for further assistance.

I signed up for electronic EOBs, why am I not getting email notifications from My Account?

Sometimes an email from a new sender will automatically go to your spam or junk mail folder. To avoid this, add CareFirst to your address book or safe senders list. See your email's "Help" option for the proper location.

Why can't I find my eEOB?

We may not have processed it yet. We process any claims we receive first, then generate EOBs for our members. Sometimes there’s a delay between each stage. You can check the status of your recent claims on My Account.

How long will it take for my claim to appear on an eEOB?

Each claim is different, and processing times will vary. However, the time it takes to process a claim typically depends on these factors:

How soon your doctor or hospital submits the claim. Almost 80% of claims are received within 30 days of the service date. Sometimes, it can take up to 60 days before your doctor or hospital submits a claim.
How quickly we process the claim once it’s received. More than 90% of claims are processed within seven days of receiving them.
Whether you have gone to an out-of-network doctor or hospital. If you have, two other factors may affect how long it takes to process your claim:
- Whether the doctor or hospital requires partial or full payment at the time of service.
- Whether the doctor or hospital can bill us directly or needs you to submit a medical claim form.

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About Claims

What is a Claim?

A claim is an official document that details what kind of care you received so CareFirst can pay your medical provider. A claim will include details about your care, including relevant procedures, exams, prescriptions, etc.

CareFirst processes claims based on your benefits. For any claim submitted to CareFirst, you’ll get an EOB, which shows how your benefits were applied and what you may owe your provider.

When do I need to submit a claim?

When you visit doctors, facilities and pharmacies who participate in CareFirst’s network (also called in-network providers), there is no need to submit a claim.

However, if you choose to see an out-of-network provider, you may have to submit the claim form yourself. Visit our Submit a Claim page to learn how.

Please note: If you're receiving ongoing treatment, you may submit a claim after each treatment.

I received care from a healthcare provider outside CareFirst's service area. How long will it take to process this claim?

CareFirst’s immediate service area includes Maryland, Washington, D.C. and Northern Virginia. Any time you receive care outside this area, your claim will take additional time to process.

Who do I contact about pharmacy claims?

Check the back of your CareFirst member ID card to see who to contact about your pharmacy claim(s). If a phone number for Pharmacy isn’t listed, call the Customer Service number for assistance.

I'm receiving ongoing orthodontic treatment. Do I need to submit a claim for each visit?

No. If comprehensive orthodontic treatment has been approved, benefits for periodic treatment visits will be automatically paid quarterly.

Submitting Claims

How do I file a claim, and how is it processed?

HOW IS MY CLAIM PROCESSED?

Visit your PCP

Up to 1 year

PCP submits claim

Every time you receive care from an in-network provider, they fill out a claim form and submit it to CareFirst. Providers have up to one year to submit a claim after the date of service.

30 days

CareFirst processes claim

Claims are entered into our system and processed according to your benefits. It takes us about 30 days to process new claims.

EOB is sent

We will then send you an EOB by mail or electronically, so you know how your benefits were applied.

Please note: When you receive care from an out-of-network provider, you may have to submit the insurance claim yourself. For step-by-step instructions on how to file a claim, visit our Submit a Claim page.

Can I use one itemized bill for multiple service/claim lines?

Yes, a single itemized bill may be used if all services you submit for payment are listed on the bill. Also, scanned images of bills are acceptable. If multiple services are included on one receipt, you do not need to upload the same bill for each service. You may upload it once.

The following file formats are acceptable for uploads: .bmp, .jpg, .pdf, .png, and .tiff. You may attach up to 20 items with each claim. The total combined size of all attached items cannot exceed 20MB.

What are a National Provider Identifier (NPI) and Tax Identification Number (TIN), and why are they needed?

An NPI is a federally assigned provider number to identify the provider’s credentials and to ensure the provider is a valid medical practitioner.

A TIN is assigned to all businesses. If the provider is not contracted with CareFirst, and/or does not provide the NPI, the TIN is used to ensure services are rendered by a valid practitioner and are reimbursable.

I am a plan member but not the policyholder. Can I still submit claims?

Yes. You must be at least 18 years old to submit a claim. However, claim(s) payments will only be issued to the policyholder.

Understanding Your Claims

Why was my claim denied?

An explanation can be found in your EOB. However, if you have additional questions, please call the Customer Service number on the back of your member ID card.

Why didn't CareFirst make a payment on my claim?

The allowed charge could have been applied to the member’s cost share (deductible, coinsurance or copay). Or payment could have been denied with a message indicating the reason. Please review your EOB for details.

Why don't I see the amount paid for all medical claims?

The amount paid is only displayed for medical claims that have been processed. The other claims shown are still being processed (pending) or have been denied.

The out-of-pocket cost information does not seem correct. What should I do?

The out-of-pocket costs show the amount you've paid toward your deductible(s) and out-of-pocket maximums. If you have questions about how those costs are calculated, please call Customer Service at the number on the back of your member ID card.

What is a statistical or upward adjustment, and how do I know if my claim has had one?

A statistical adjustment is a change to your claim that does not impact payments or dollar amounts. An upward adjustment is a change that may impact payments or dollar amounts, and benefits the patient. If a claim has had either adjustment, it will be noted with a Remark Code.

Which family members' claims can I view?

IN MOST CASES

Policyholders can view all family members’ medical and dental claims. They can also view pharmacy claims for dependents under 12.

Spouses/Domestic Partners of policyholders can view medical and dental claims for dependents under 18 and pharmacy claims information for dependents under 12.

Dependents 12 & Over can view their claims by registering for their own My Account.

Please note: Various state and federal laws dictate who can see what information regardless of the relation.

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About Inquiries and Appeals

My claim was denied by CareFirst. What are the next steps to investigate it?

INVESTIGATING A DENIED CLAIM

If not resolved

File an inquiry

Submit a written appeal

CareFirst will review appeal

Appeal decision will be mailed to you

What is an appeal, and who can submit one?

An appeal is a timely request for a formal review of an adverse benefits decision, such as a claim denial or how we applied your deductible or coinsurance. You, an authorized representative, or a provider acting on your behalf have the right to file a written appeal.

How does the appeal process work?

All members have a right to a formal internal review(s) of the claim decision. Many members also have a right to an independent external review of any final appeal decision.

There is a limit to the number of times you may appeal a decision. The limits and deadlines to submit your appeal(s) are described in your plan documents.

On each level of appeal, a written response will be sent to you within the timeframe required by law. The response will let you know if there are additional steps you can take. If you exhaust your levels of appeal, the response will notify you to that effect.

Please note: The appeal process also includes an expedited process for use in the case of a claim involving urgent care to obtain a decision within 72 hours of the date the appeal is filed. If your situation meets the definition of urgent under the law, your review will be conducted on an expedited basis.

About Prior Authorization

What is prior authorization?

Prior authorization (also known as pre-authorization or pre-certification) is a tool health plans use to ensure a prescribed product, service or medication is safe, appropriate and effective.

Prior authorization means, in certain circumstances, your health plan must approve (authorize) specific products, services or medications BEFORE (prior) you receive them to get the coverage you need. Without this approval, you may be denied care or have to pay the entire cost.

Why is prior authorization important?

Prior authorization ensures health professionals adhere to nationally recognized care criteria. It provides an extra layer of review to help prevent errors that can jeopardize a person’s health.

When do I need to get prior authorization for a prescribed procedure, service or medication?

When you receive care in-network, your primary care physician or specialist is usually responsible for obtaining prior authorization for specific procedures, services and medications. For out-of-network services, you are typically responsible for obtaining prior approval. In this case, we recommend working with your provider to ensure you submit the required clinical information.

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Terms

Allowed Amount/Allowed Charge

The allowed amount (or allowed charge) is the maximum amount your insurance plan will pay for a single covered healthcare service. Healthcare providers working in our network are subject to limits that they can charge for care, as determined by CareFirst. They can’t charge more than the amount they agree to.

Out-of-network providers may charge more for their services. If you see an out-of-network provider, you may be responsible to pay the difference between their price and the CareFirst allowed amount.

Benefits

Your benefits are the services covered by your plan. Depending on the plan you have, your benefits may cover the entire amount charged for the service(s) or a partial amount.

CareFirst Member Discount

With CareFirst BlueCross BlueShield, you pay less than you would without insurance. That’s because we negotiate with providers to set discounted rates to make sure you have affordable access to the care you need.

Claim

A claim is an official document that details what kind of care you received so that CareFirst can pay your medical provider. A claim will include details about your care including relevant procedures, exams, prescriptions, etc.

CareFirst processes claims based on your benefits. For any claim submitted to CareFirst, you’ll get an Explanation of Benefits (EOB). The EOB shows how your benefits were applied and what you may owe your provider. Depending on when claims are submitted, your EOBs may include details for multiple claims.

Claims Statement Summary

Think of it as a bank statement. But instead of summarizing what you paid and/or deposited over a certain period of time, your Claims Statement summarizes your most recent insurance claim(s)—showing what care you received, what your plan covered, how much you saved, and how much you may owe.

Coinsurance

Coinsurance is the amount you pay for a covered service after you’ve reached your deductible. It’s usually expressed as a percentage of the total cost of the service.

For example, imagine a visit to your doctor ends up costing $200 and you have 10% coinsurance. If you haven’t reached your deductible, you’ll owe the full $200. If you have reached your deductible, you’ll owe 10% of the bill, which is $20.

Copay

A copayment or copay is a flat fee you’ll pay for specific services under your plan. Usually, there is more than one kind of service covered by a copay. For example, you may pay a $10 copay for visits to your primary care physician, $100 for seeing a specialist and $500 for a trip to the emergency room.

Your copays don’t usually count toward your deductible, but they do count toward your out-of-pocket amount.

Deductible

Your deductible is a fixed dollar amount that you must pay out-of-pocket every plan year before CareFirst pays its portion of your care. For most plans, any money you pay toward the allowed charge for care will count toward your overall deductible. Premiums, however, don’t count toward your deductible.

Your deductible depends on the health plan you choose. Many CareFirst health plans cover preventive services before you meet your deductible.

Out-of-Pocket

The out-of-pocket amount is the most you’ll have to pay for care during your plan year. For most plans, the allowed amount that you pay for deductibles, copays, coinsurance and prescription drugs counts toward your overall out-of-pocket maximum. Once you reach your out-of-pocket maximum, CareFirst pays 100% of your care. However, you’re still responsible for plan premiums.

Premium

Your premium is the amount you pay regularly for your insurance plan. For most folks, it’s your monthly bill. It does not include what you may owe for copays, coinsurance or your deductible.

Total Provider Charges

This is the raw cost of the medical service detailed on your claim—what you would pay if you didn’t have medical insurance at all.

Explore our complete health insurance glossary to learn other important terms and acronyms.

Explore Glossary

Have Additional Questions?

Contact Us

Log into My Account, select Help in the top header and click on Contact Us in the drop-down menu.

Call

Call the number on the back of your member ID card to speak with a Customer Service representative.