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What is an Explanation of Benefits?


An Explanation of Benefits (EOB), also known as a claim statement, is NOT a bill. It is a statement provided to you by the claims payor.

An EOB is provided to you after you or your provider have submitted a claim for a health or dental service or product. It is also provided if you have submitted an estimate for a health or dental service or product covered under your plan.

The EOB can show:

  • What health or dental services were paid for under your benefits plan.
  • What health or dental services will be eligible under your benefits plan.
  • How much you are responsible for paying ‘out-of-pocket’.

How to find your claim statement or EOB

After you have logged into the OTIP member site, you can review your claim statement or EOB in Claims History in My Claims (see example image below). Your claim statement or EOB will also be mailed to you if you have not consented to the electronic transfer of funds.

Claims-history-EN.PNG


Beside each claim, you can click on the document icon under the Statement column to review:

  • Your plan details including your plan and claim number.  
  • The details of the claim or estimate, including the date of expense if applicable, the specific services or products and the amount that was charged or will be charged for those services or products.
  • The eligible amount, the percentage paid and the benefit amount that your plan reimbursed or will reimburse for those services or products. EOBs issued on estimates may also advise you how much of a benefit you have used out of your plan maximum.
  • If the amount is not paid, the EOB will note other information required, such as a request for additional supporting information to determine eligibility of coverage under your plan.

Claim statement or EOB example

Example-EOB-EN.png


NOTE: Claim statements or EOBs are not available for drug claims paid directly to the pharmacy. If you are covered under another benefits/insurance plan, where you do not have a benefits card, we encourage you to retain copies of your original claims or pharmacy drug receipts. If you are required to pay amounts not covered by your Employee Life and Health Trust benefits plan, you will need to include your pharmacy drug receipts for the amount you paid for claim assessment with the other plan. Learn more about co-ordination of benefits.
 
In addition, your claim statements or EOB can also be used when claiming unpaid portions of health or dental expenses on your income tax return.

Important things to remember about your claim statement/EOB

It’s important to find out how much is covered under your benefits plan and how much you may be responsible for paying ‘out-of-pocket’. This will help you to minimize expenses and avoid disappointment if your claim is not eligible for full or partial reimbursement.


TIP: Before you spend your money on health or dental services, we encourage you to get an estimate or pre-determination, check if your service provider has been delisted and review your reasonable & customary (R&C) limits.

 






To prevent benefits fraud, remember to compare your EOB to the bill you receive from your service provider to ensure they match. If the amount does not match your EOB, contact OTIP Benefit Services at 1‑866‑783‑6847 or your provider.
 
If you are having trouble reading your EOB, or need help understanding the charges for services shown, we are here to help. Contact OTIP Benefit Services at 1‑866‑783‑6847 or send us an email.

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