Explanation of Benefits (EOB) codes are standardized codes used by health insurance companies to explain the actions and decisions related to a claim. These codes help communicate to healthcare providers and patients the outcome of a claim submission, including payments, denials, adjustments, and reasons for those actions. While the specific codes may vary slightly between insurance companies, there are common themes in EOB code listings. Here's a general breakdown:
Claim Status Codes:
These codes indicate the status of a claim, whether it has been paid, denied, or is pending further review.
Examples:
"P" for paid
"D" for denied
"R" for rejected
Claim Adjustment Reason Codes (CARCs):
These codes explain why a claim was adjusted, including denials or reductions in payment.
Examples:
"CO-16" - Claim or service lacks information/is incomplete or has submission/billing errors
"PR-204" - The service/equipment/drug is not covered under the patient's current benefit plan
"OA-23" - The impact of prior payer(s) adjudication including payments and/or adjustments
Remittance Advice Remark Codes (RARCs):
These codes provide additional information or clarification regarding the claim adjustment.
Examples:
"N130" - Consult our contractual agreement for more information
"M144" - Missing/incomplete/invalid days or units of service
"N381" - This is a separate charge from a hospital, ambulatory surgical center, or other provider for the administration of the same drug or biological.
Payment Adjustment Codes:
These codes specify adjustments made to the payment amount, such as deductibles, co-payments, and coinsurance.
Examples:
"PR-1" - Deductible amount
"PR-2" - Coinsurance amount
"PR-3" - Co-payment amount
Service Codes:
These codes identify the specific services provided, allowing the recipient to understand which procedures or treatments were covered.
Examples:
"99213" - Typically, evaluation and management of an established patient is 15 minutes in duration
"80053" - Comprehensive metabolic panel, a blood test that measures your sugar (glucose) level, electrolyte and fluid balance, kidney function, and liver function
Understanding these codes can help healthcare providers and patients navigate the reimbursement process and address any discrepancies or issues that arise with insurance claims.