Advanced Explanation of Benefits (AEOBs)

Advanced Explanation of Benefits (AEOBs) are the final step in the process of providing insured individuals accurate estimates of the cost of items or services as outlined by the No Surprises Act (NSA). Think of these as the insurer equivalent of a Good Faith Estimate (GFE). Items or services are defined as any individual item, service, or service package that could be provided to a patient for which the facility or provider has an established charge. AEOBs must be delivered in language a patient can easily understand (this is defined as “plain language”) via mail or electronic means as specified by the individual and they must contain the following:

Information

• Whether or not the provider or facility is a participating (meaning in-network) provider or facility
  • If so, the contracted rate for the items or services
  • If not, how the individual can obtain info on participating providers or facilities, if there are any
• The corresponding GFE included in the notification received from the provider or facility
• A GFE for the amount the plan or coverage is responsible for paying items and services
• A GFE for the patient’s cost-sharing amount for such item or service as of the date of notification
• A GFE for the amount incurred toward meeting the patient’s limit of financial responsibility (defined as the patient’s deductible and out-of-pocket amounts) at the time of request

Prerequisites

• Notice of prerequisites, if applicable (concurrent review, prior authorization, or the step-therapy/fail-first approach of prescribing patients less expensive medication before more costly medication is authorized)
  • These prerequisites are defined by the patient’s insurer and are separate requirements that, if not met, could lead to payment denial. For example, a patient could be expected to get prior authorization granted by the insurer confirming a knee replacement procedure is medically necessary before scheduling the surgery.
• Disclosure Notice: predetermined list of disclosures provided by The Centers for Medicare and Medicaid Services (CMS)

Time Limitations of the No Surprises Act (NSA)

Insurers must provide an AEOB within one business day after the date the patient scheduled an appointment to receive items or services or requested the AEOB unless the items or services were scheduled at least 10 days in advance. If that’s the case, an AEOB is subsequently required within three business days.

Due to data interoperability issues, insurers are struggling to effectively and accurately complete AEOBs without claim data associated with the GFE. As a result, AEOB enforcement has been delayed indefinitely.