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A Deeper Dive Into Recording EOBs

Want to learn more about recording EOBs in Jane? We’ll you’ll be an expert after reading this guide!

What is an EOB?

EOB stands for Explanation of Benefits. EOBs are documents sent from insurance companies (sometimes sent electronically as ERAs - which stands for Electronic Remittance Advice) that provide details on how a claim or claims should be reconciled.

For an individual claim, EOBs typically show what was billed, what was allowed for the amount billed, the amount the insurer is paying, the patient responsibility (i.e. copayment), as well as any unallowed amount, uncovered amount (for various reasons), or necessary adjustments.

How do I record my EOBs in Jane?

In a nutshell, you should be able to take the information from the EOB you’ve received from an insurance company and enter it into Jane’s EOB screen to determine your final patient and insurer invoicing.

Let’s break Jane’s EOB screen down into a three parts:

Section 1: Pre-EOB Information

The first portion of your EOB includes information about the claim you’re working with.

This area includes:

  • the invoice number
  • the patient’s name
  • the patient’s insurance policy Member/Subscriber ID
  • the date of service
  • the type of appointment

Additionally, Jane displays how the claim is currently invoiced in your Jane account. More specifically, Jane shows the patient responsibility (Copay, Coinsurance, and/or Deductible) assigned to the patient before recording the EOB. This area typically shows how the claim was invoiced at the time of service.

This area is handy as reference information when posting your EOB since you can compare the ‘current’ or ‘time of service’ amounts with the information included in the EOB.

For example, if the current invoicing is lower than what’s presented in the EOB (what you invoiced the patient at the time of service is lower than what the insurer is saying the patient should pay after processing the claim) then this means you’ll create an additional patient outstanding balance once you’ve applied the EOB.

Section 2: Service Line Adjudication

Each billed procedure has its own line on the EOB screen. This applies to both unique procedures as well as multiples of the same procedure. For example, if you bill 4 units of massage, there will be 4 services lines - one for each multiple of the procedure.

For each service line, you can enter the following 5 EOB values:

  1. Allowed Amount - enter what the insurer allows for this code.
  2. Paid Amount - enter the amount the insurer is paying towards this code
  3. Copay - enter the patient copay dollar amount for this code.
  4. Coinsurance - enter the patient coinsurance dollar amount for this code.
  5. Deductible - enter the dollar amount going towards the patient deductible for this code.

In addition to adding the appropriate numbers to these five areas, Jane also asks how you’d like to manage these amounts:

  • For the patient responsibility fields (Copay, Coinsurance, and Deductible), Jane asks if you’d like to bill the patient directly for these amounts - Bill to Patient - or if you’d like to pass that amount down to the patient’s secondary insurance if present - Bill to Next Payer.

  • If there is a difference between the Billed Amount of the procedure (the billing code amount) and the Allowed Amount, Jane asks how you’d like to handle that difference. There are three different options to choose from: Adjust, Collect from Next Payer, or Leave Outstanding.
    • If you’re contractually obligated to not charge the patient that difference, you’ll want to select the Adjust By option.
    • If you’d like to invoice the patient’s secondary insurance that difference, you’ll want to select the Collect From Next Payer option.
    • If you do plan on receiving that difference from the insurer (i.e. you need to re-bill the claim), you’ll want to select the Leave Outstanding option.

  • Similar to the above point, if there is a difference between the Allowed Amount and the amount you’re actually getting paid (Paid Amount + Patient Responsibility), you’ll be presented with the same three options outlined above.

Lastly, each service line has a box where you can leave notes specific to the adjudication of that code. For example, if a code was rejected because you forgot to bill a required modifier, you can write that in the notes!

Section 3: Claim EOB Invoicing Summary

The last section of the EOB provides a billing summary for the claim as a whole. Jane considers all the adjudication values you’ve entered for each service line, and outlines the invoicing changes that will be made once the EOB is applied.

Here’s a breakdown of the various figures included in this summary:

  1. Total Billed
    • The total amount of the claim that was billed to the insurer (typically the sum of the billing codes).
  2. Total Allowed
    • The sum of the Allowed Amounts for all of the billing codes.
  3. Paid By (Insurance)
    • The total amount the insurer is paying towards the claim.
  4. Patient Responsibility
    • The sum of the Copay, Coinsurance, and Deductible amounts for each billing code service line.
  5. Total Insurance Adjustment
    • The total amount billed that isn’t covered by the insurer nor passed to the patient. This is the amount that is not going to be collected for the claim.
    • Typically this represents the total amount you are contractually obligated to adjust off of the billed amount of the claim.
  6. Collect from Patient
    • The total amount of the claim that will be invoiced to the patient once the EOB is applied.
  7. Collect from Next Payer
    • The total amount of the claim that will be invoiced to the Next Payer once the EOB is applied.
    • This value is typically $0 unless the patient has secondary coverage.

This is my first time posting an EOB in Jane - can we walk through an example?

If you’re unsure how to enter what’s included in an EOB you’ve received, then an example might help!

For our example, let’s say our patient Jon comes in for a visit - and we end up billing out two procedure codes:

1) 99204 - with a Billed Amount of $150

2) 98941 - with a Billed Amount of $50

Jon has an Aetna Insurance Policy, and since we’re in-network with Aetna, we know that they allow $110 for 99204 and $40 for 98941. We also know that Jon has a 20% Coinsurance (for both these services). We enter what is allowed for each code as Allowed Amounts at the time of service as well as the 20 % Coinsurance.

Note that these Allowed Amounts along with the Coinsurance generates a $30 patient invoice at the time of service:

(20% x $110)+(20% x $40) = ($22) + ($8) = $30

Now let’s say we’ve billed out this claim and (weeks later) we’ve received an EOB as well as a payment from Aetna.

The information in the EOB might look something like this (please keep in mind that your EOB might not look exactly like this and could definitely include some different lingo!):

Code 1: 99204

  • Charge Amount: $150
  • Payment Amount (from insurance): $88.00
  • Allowed Amount: $110
  • Contractual Obligation Adjustment: $40
  • Patient Coinsurance: $22.00

Code 2: 98941

  • Charge Amount: $50.00
  • Payment Amount (from insurance): $32.00
  • Allowed Amount: $40.00
  • Contractual Obligation Adjustment: $10
  • Patient Coinsurance: $8.00

With this example, let’s breakdown what we will need to enter in the EOB screen. Additionally, let’s break our example down into the 3 different EOB sections mentioned above (Pre-EOB Information, Service Line Adjudication, & Claim EOB Invoicing Summary).

Section 1: Pre-EOB Information

When you enter the EOB screen, Jane will show you the $30 Coinsurance amount that you invoiced your patient at the time of service.

Note that although your patient’s Coinsurance shows as a percentage at the time of service, it is displayed as a dollar amount in the EOB (as Coinsurance typically appears as a dollar amount in EOBs).

You don’t need to do anything in this area! It is just meant as helpful reference info (so you know what was invoiced at the time of service).

Section 2: Service Line Adjudication

  1. 99204 Line

    For reference, we were given the following information from the EOB for the adjudication of our first code:

    • Charge Amount: $150
    • Payment Amount (from insurance): $88.00
    • Allowed Amount: $110
    • Contractual Obligation Adjustment: $40
    • Patient Coinsurance: $22.00

    Here’s a snippet of how we can enter that information into Jane.

  2. 98941 Line

    For reference, we were given the following information from the EOB for the adjudication of our second code:

    • Charge Amount: $50.00
    • Payment Amount (from insurance): $32.00
    • Allowed Amount: $40.00
    • Contractual Obligation Adjustment: $10
    • Patient Coinsurance: $8.00

Here’s a snippet of how we can enter that information into Jane.

Some Key Notes:

  • The Contractual Adjustment (or Insurance Adjustment in Jane terms) is automatically calculated in Jane. Jane calculates the difference between the Billed Amount and Allowed Amount, and asks how you’d like to handle the difference. If you won’t be collecting the difference, then Adjust By is the option you’ll want to choose (which is also the default).
  • In this example EOB, we were explicitly give the Allowed Amount and the Contractual Obligation Adjustment. However, sometimes you are just given the Contractual Adjustments and need to deduce the Allowed Amount yourself. If that’s the case, then you should be able to calculate the Allowed Amount by adding the amount the insurer is paying with the patient responsibility.
  • For both billing codes, we entered the Coinsurance as a dollar amount rather than a percentage!

Section 3: Claim EOB Invoicing Summary

After you’ve entered your Service Line information, here is what you’re summary will look like!

The last step is to click the Apply Changes button to officially record the EOB! 🎉

What happens if I make a mistake?

Once you’ve recorded your EOB, Jane will update your patient and insurer invoicing accordingly. In doing so, Jane also locks down the appointment insurance panel so that you can no longer alter the appointment’s Allowed Amounts, Copay, Coinsurance %, or Deductible.

If you try to edit these fields after an EOB has been entered, you’ll be presented with a lock symbol. 🔒

The reason why you cannot adjust these fields from the appointment panel after an EOB has been recorded is because Jane doesn’t want to make any assumptions on how these changes should be reflected in the EOB!

For example, let’s say you billed out three procedure codes, and the total patient Co Pay amount entered in the EOB (for all three codes) was $20. But, after applying the EOB you realize you’ve made a mistake and the total patient Co Pay should be $30. If you were to edit the Co Pay in the insurance panel, then Jane wouldn’t know which of the three billing codes to assign that additional $10 to.

So, instead of changing the Co Pay from $20 to $30 on the insurance section of the appointment, you’ll just need to re-enter the EOB (which you can conveniently do from the appointment as well).

To edit a previously recorded EOB, head to the appointment or purchase, click the claim dropdown, and select the Edit EOB option. From there you can re-enter your EOB as needed and apply your changes!

If you have any questions about recording EOBs we’d love to hear from you! Use the Help button from within your Jane account or email us at support@janeapp.com.