Understanding Basics of Behavioral Health EOB


Understanding Basics of Behavioral Health EOB

Date Posted: Wednesday, June 05, 2024


Understanding how insurance companies work can be a challenging task for behavioral health providers. Navigating Explanation of Benefits (EOBs) is crucial for ensuring proper reimbursement and a smooth claims process. This guide will equip you with the knowledge to decipher these often-confusing documents.


What Is a Behavioral Health EOB and Why Is It Important?


An EOB is a document sent by an insurance company to a patient after a healthcare service is rendered. It details how the insurance company processed the claim submitted by the provider (you). The EOB outlines the charges for the service, the portion covered by the insurance plan, and the remaining patient responsibility.


Understanding EOBs is vital for behavioral health providers for several reasons:


  • Ensures Accurate Reimbursement: A clear understanding of the EOB allows you to verify if the insurance company processed the claim correctly and paid you the appropriate amount.
  • Identifies Billing Errors: EOBs can reveal potential billing errors on your part, allowing for timely corrections to avoid claim denials.
  • Improves Patient Communication: By understanding the EOB, you can effectively communicate with patients about their financial responsibility for the services rendered.


Breaking Down the EOB


EOBs can vary slightly depending on the insurance company, but typically follow a similar format. Here’s a breakdown of the key sections:


  • Patient Information: This section verifies the patient’s name, policyholder information, and date of service.
  • Service Details: This section details the specific service provided, including the date, provider name, and a Healthcare Common Procedure Coding System (HCPCS) code that identifies the service rendered.
  • Charges: This section shows the total amount you billed the insurance company for the service.
  • Adjustments: This section may show adjustments made by the insurance company, such as discounts or contractual rates negotiated with your practice.
  • Allowed Amount: This crucial section displays the amount the insurance company deems “allowable” for the service based on the patient’s plan benefits.
  • Benefits Applied: This section details how the insurance plan benefits were applied to the allowed amount. This may include the patient’s deductible, copay, and coinsurance.
  • Patient Responsibility: This section clearly shows the amount the patient owes for the service after applying for insurance benefits.
  • Payment Information: This section provides instructions on how and where the patient can submit payment.


Common Terms in a Behavioral Health EOB


Here’s a quick reference guide for some key terms you’ll encounter on a behavioral health EOB:

  • Deductible: The annual amount a patient must pay out-of-pocket before the insurance plan starts covering costs.
  • Co-pay: A fixed dollar amount the patient pays for a covered service at the time of service.
  • Coinsurance: A percentage of the amount the patient is responsible for paying after the deductible is met.
  • Allowed Amount: The maximum amount the insurance company will reimburse for a specific service after considering plan benefits and network participation.
  • Non-Covered Services: Services not covered by the patient’s insurance plan. The patient is responsible for the full cost.


Understanding these terms will allow you to interpret the EOB and explain it clearly to your patients.


Understanding HCPCS Codes


EOBs utilize HCPCS codes to identify the specific behavioral health service provided. These alphanumeric codes are crucial for accurate claims processing. While memorizing all codes is impractical, familiarizing yourself with common behavioral health codes used in your practice can be beneficial.


Here are some resources to help you look up specific HCPCS codes:


  • Centers for Medicare & Medicaid Services (CMS)
  • American Medical Association (AMA)


What to Do When an EOB Shows a Denial?


Sometimes, insurance companies may deny claims for various reasons. Common reasons for claim denials in behavioral health include:


  • Lack of prior authorization for specific services.
  • Incorrect or missing HCPCS codes.
  • Services deemed medically unnecessary by the insurance company.


If you receive an EOB with a denied claim, don’t panic. Here are some steps you can take:


  • Review the EOB Carefully: Identify the reason for the denial as stated by the insurance company.
  • Verify Your Coding: Double-check the accuracy of the submitted HCPCS codes.
  • Contact the Insurance Company: Call the insurance company’s provider services department to understand the denial and inquire about the appeals process.
  • Gather Supporting Documentation: If necessary, gather documentation to justify the service, such as treatment notes or progress reports.
  • Submit an Appeal: File a formal appeal with the insurance company, outlining why the service should be covered and attaching any supporting documentation.


By understanding behavioral health EOBs, you can ensure proper reimbursement, identify billing errors promptly, and effectively communicate with patients about their financial responsibility. Remember, staying informed about billing practices and utilizing available resources will contribute to a smoother claims process for your practice.


By Medisys

Medisys, a leading behavioral health billing company, can be your partner in navigating the complexities of behavioral health billing. This team of certified coders and billing specialists can ensure accurate claim submissions, handle denial management, and provide clear explanations of EOBs. This allows you to focus on what matters most: providing quality care to your patients. Learn more about how Medisys can streamline your behavioral health billing process. Contact Medisys at 888-720-8884 / info@medisysdata.com to learn more.





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