Explanation of Benefits (EOB)

What your EOB can tell you

An Explanation of Benefits (EOB) gives you details about health care services your child recently received. It details what you may owe or how much you may have paid for the service. EOBs are not bills.

We know EOBs can be confusing. That’s why we’ve designed ours to be easier to understand. Watch the video below and review our quick guide (PDF) | Tutorial de la Explicación de Beneficios (PDF) to learn about your child’s new EOB.

I received both an EOB and a bill. What is the difference?

• EOBs provide an overview of the medical services your child received. They outline what you owe or may have paid your child's provider. When you receive an EOB, there is no expectation for you to take action, such as making a payment. However, your EOB will tell you what you can do if something looks wrong.
• Receiving a bill means that you have a balance that you need to pay to your child's provider. UPMC Health Plan will not send you bills for medical services your child received.
  • If your child received medical care from a UPMC provider, you can use our self-service resources to pay your bill at myUPMC.

Have questions? Check out some of the frequently asked questions below to see if we have an answer for you!

• What is a copay?
  The specified dollar amount that you pay at the time of service for certain covered benefits. Please refer to your Summary of Benefits to determine Copayment amounts or view the Summary of Benefits (PDF).


• What if something looks incorrect?
  If you disagree with the benefit determination that UPMC for Kids made for the claim(s) covered on this EOB, you may request that the decision be reviewed. UPMC for Kids has established an internal process to review all member complaints and grievances.


• What if I still have questions?
  Please call our Health Care Concierge team at 1-800-650-8762 for further questions. TTY users should call 711. We are available to answer your calls Monday through Friday from 8 a.m. to 6 p.m.


• Why am I seeing a claim denial on my EOB?
  There are reasons why a claim may show as denied on your EOB. A few examples are that the service was not deemed medically necessary, the service was not appropriate for the specific health care setting or level of care, the effectiveness of the medical treatment has not been proven, or the service is not a covered benefit. If you have questions about other services and supplies that UPMC for Kids does not cover or services that have coverage limitations, you can refer to the Exclusions booklet.