Dental Explanation of Benefits (EOB) Explained

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Subscriber and patient informationHeader

The subscriber name, member ID, group number and the patient who received treatment. Check these first: a mismatch can mean the claim was processed under the wrong person or plan.

Claim numberHeader

The carrier's reference number for this claim. Use it on every phone call, corrected claim and appeal about this claim.

Dentist informationHeader

The treating dentist or practice the carrier paid or considered, with network status. If it shows out of network when the dentist is credentialed, contact the carrier before posting.

Dates of serviceService line

The date of each procedure. Eligibility, waiting periods, frequency limits and the benefit year are all judged against these dates.

Procedure code and toothService line

The CDT code processed on each line, with tooth number, surfaces or quadrant. Compare it to what you billed to spot a downgrade or recoding by the carrier.

Submitted feeAmounts

The fee the office submitted for each procedure, based on the practice's full fee schedule. It is the starting point, not what an in-network dentist expects to receive.

Allowed amount (maximum allowable fee)Amounts

The most the plan recognizes for the procedure under the PPO fee schedule or plan rules. Carrier payment and patient share add up to this amount for in-network treatment.

PPO write-off (contractual adjustment)Amounts

The difference between the submitted fee and the allowed amount that an in-network dentist agreed to write off. It is usually not billable to the patient.

Alternate benefit or downgradeAmounts

A note that the plan paid the procedure at the fee of a less costly alternative, such as a posterior composite paid at the amalgam fee. Whether the patient owes the difference depends on the plan and your contract.

Not covered or limitation amountAmounts

Fees the plan did not pay because of a frequency limit, waiting period, exclusion or missing information, with a reason code. Read the reason before billing the patient.

DeductiblePatient share

The part of the allowed amount applied to the patient's annual deductible. Many dental plans waive the deductible for diagnostic and preventive care.

Coinsurance percentagePatient share

The share of the allowed amount the plan pays for the procedure category, often different for preventive, basic and major services. The patient owes the rest.

CopayPatient share

A fixed amount the patient owes per procedure, common on DHMO plans, which may already have been collected at the visit.

Paid amount (carrier payment)Amounts

What the carrier actually paid for each line. Compare it to your PPO fee schedule and the coinsurance percentage to catch underpayments.

Patient responsibilityPatient share

The total the patient owes for the claim: deductible plus coinsurance plus copay plus any non-covered amount the patient is liable for. This is the figure to bill the patient or a secondary plan.

Other insurance paidAmounts

Amounts paid by another dental plan under coordination of benefits. It appears when this plan is secondary or when the carrier believes another plan is primary.

Adjustment reason and remark codesCodes

Codes or notes that explain each adjustment or denial, such as a frequency limit, a missing x-ray or an annual maximum reached. They tell you whether to bill the patient, send records, correct the claim or appeal.

Payment detailsPayment

The check or EFT number, payment date and total paid. Use them to match the EOB to the bank deposit when posting.

Annual maximum and deductible usedPlan totals

Year-to-date totals for the deductible and the annual maximum, and sometimes the orthodontic lifetime maximum. They help predict the patient's share on the next treatment plan.

Sample dental EOB: submitted fee and allowed amountSample EOB

In this made-up example, an in-network office bills a crown on tooth #30 at its full office fee of $1,200. The carrier's PPO fee schedule allows $900 for that code, so the EOB shows a $300 PPO write-off that the patient does not owe.

Sample dental EOB: deductible and coinsuranceSample EOB

Of the $900 allowed, $50 goes to the patient's remaining annual deductible. The plan covers crowns as a major service at 50 percent, so it pays half of the remaining $850, which is $425.

Sample dental EOB: patient responsibilitySample EOB

The patient owes the $50 deductible plus the other half of $850, or $425, for a total of $475. Carrier payment ($425) plus patient share ($475) equals the $900 allowed amount, a quick check that the line was processed as expected.

Sample dental EOB: annual maximum checkSample EOB

The plan totals show the $425 counted against the annual maximum. If only $300 of the maximum had been left, the carrier would pay $300 and the other $125 would shift to the patient, raising the patient share to $600.

Appeal rightsAppeals

Instructions and deadlines for asking the carrier to reconsider its decision. Note the deadline as soon as a denial is posted.