Скачать или смотреть ERAs vs EOBs Payment posting terms simplified

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ERA and EOB in medical billing — two vital components of the claims reconciliation and payment posting process.
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📘 Overview: ERA vs EOB
Feature ERA EOB
Full Form Electronic Remittance Advice Explanation of Benefits
Format Digital (EDI 835 file) Paper (or PDF for patients)
Recipient Healthcare provider/biller Patient
Purpose Explains how/why a claim was paid or denied Informs the patient of the insurance payment decision
Content Claim-level details, adjustments, denial codes (CARC/RARC) Summary of services, what insurance paid, what patient owes
Delivery Sent electronically via clearinghouses or payer portals Sent via mail or patient portal
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🔹 1. What Is an ERA (Electronic Remittance Advice)?
➤ Definition:
An ERA is an electronic version of a paper remittance advice or EOB, formatted in HIPAA-compliant EDI 835 standards. It explains how the insurance payer processed the claim, including payments, adjustments, and denials.
➤ Key Details Included in an ERA:
• Claim and patient identifiers
• Billed amount vs allowed amount
• Paid amount
• Adjustments (CARC/RARC codes)
• Denials (with codes)
• Patient responsibility
• Coordination of benefits (COB)
• Payment method (EFT, check, etc.)
➤ Who Uses It:
• Billing teams
• Practice management software
• RCM vendors
➤ Format:
• EDI 835 file
• Uploaded directly into billing software
• Supports automated payment posting
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🔹 2. What Is an EOB (Explanation of Benefits)?
➤ Definition:
An EOB is a patient-facing document sent by the insurance company to inform the patient what was billed, what insurance paid, and what they owe.
➤ Key Details Included in an EOB:
• Patient’s name and ID
• Provider name and date of service
• Description of services/procedures
• Amount billed by provider
• Amount covered by insurance
• Deductible/copay/coinsurance applied
• Reason for any denial or adjustment (in simple language)
• Remaining balance owed by the patient
➤ Who Uses It:
• Patients
• Sometimes provided to billing staff for manual payment posting if ERA is not available
➤ Format:
• Paper or PDF (not EDI)
• Mailed or made available via patient portal
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🔄 Key Differences at a Glance
Attribute ERA (Electronic Remittance Advice) EOB (Explanation of Benefits)
Audience Provider/biller Patient
Format Electronic (EDI 835) Paper or PDF
Content Complexity Technical and includes codes (CARC/RARC) Simplified, easy for patient understanding
Purpose Automates payment posting and denial management Explains coverage and patient responsibility
System Use Imported into billing software for posting Used manually, usually not system-readable
Delivery Method Via clearinghouse, payer portal, or EHR Sent by mail/email to patient
HIPAA Format Yes (EDI 835) No
Denial Codes Yes (technical codes) Sometimes, but simplified or omitted
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🔍 Example Comparison
🎯 ERA (for provider):
• CPT 99213 | Charge: $150
• Allowed: $120
• Paid: $80
• Adjustment: $40 (CARC 45 – Exceeds Fee Schedule)
• Patient Responsibility: $40
• RARC: N130 – Consult plan benefit documentation
📩 EOB (for patient):
• Service: Office Visit
• Provider Charged: $150
• Insurance Paid: $80
• Your Responsibility: $40
• Reason: Your plan does not cover the full amount for this service.
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⚙️ When Are They Used?
Situation Document Used
Automated Payment Posting ERA
Patient Dispute or Query EOB
Claim Denial Follow-Up ERA
Patient Communication EOB
Secondary Billing Support ERA + EOB (to show proof of primary payment)
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✅ Summary: Why It Matters
Role What They Should Use
Billing staff ERA for efficient posting, tracking, and appeals
Patients EOB to understand their benefits and out-of-pocket cost
RCM leadership Both, for tracking denials, appeals, and patient balances
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📚 Bonus Tip: When EOB is Used Instead of ERA
• If a payer doesn’t support ERA or it’s not set up, the billing team may manually post payments using EOBs.
• Smaller practices, out-of-network services, and paper-based payers often rely on EOBs.