Advance Explanation of Benefits: the 411

What is it?

An Advance Explanation of Benefits (AEOB) starts with the obligation of a health care provider to furnish a patient with an advance statement of the expected charges for a scheduled service.

When do I have to provide it?

• An AEOB must be furnished no later than 1 day after the date* of such scheduling; or
  • *if the scheduling occurs at least 3 days before the date the service is to be provided
• no later than 3 business days after the date* of scheduling.
  • *if the scheduling occurs at least 10 days before the date the service is to be provided

What next?

If the individual is covered by a health plan, the statement must be submitted to the plan.

Upon receipt of the statement, the plan must give the individual an EOB; it must indicate:

• Whether the provider is in-network or out-of-network.
• The contracted rate if the provider is in-network.
• If the provider is out-of-network, how the individual can get information about in-network providers.
• The estimate given on the statement from the provider.
• A good faith estimate of the amount (1) the plan will pay; (2) of cost sharing that the individual must pay; and (3) the individual has incurred toward meeting his or her cost sharing limits.

What else?

• If coverage for the service is subject to prior authorization, concurrent review, or other medical management techniques, the AEOB must include a disclaimer to that effect.
• Additionally, the plan must provide a disclaimer that information within the AEOB is only an estimate. It may include any other information or disclaimer that the plan deems appropriate, consistent with the requirement of the law.
• The AEOB must be provided within 1 business day after receipt of the notification from the provider unless the service is scheduled at least 10 days in advance, in which case the plan has 3 business days to provide the Advance EOB.

These requirements apply for plan years beginning on or after January 1, 2022.