INDUSTRY FIELD GUIDE
Health insurance explanation-of-benefits records for AI
A billed amount, an allowed amount, and an amount actually paid can all appear on the same explanation of benefits.
NAICS 524114 · Direct Health and Medical Insurance Carriers
A billed amount, an allowed amount, and an amount actually paid can all appear on the same explanation of benefits. CMS provides an example explaining those fields. A health insurer can create a fully synthetic test to see whether an assistant summarizes an adjustment with the correct line item and version. CMS explanation-of-benefits guide
Create a practice EOB with two generic service lines and a corrected amount on one. Add a separate provider statement and label it as a different type of record. Ask the model to explain what changed without assuming that a displayed figure is a bill. Check amount type, service reference, and documentary source. Keep appeals and coverage decisions outside the task.
Use no real claims, patient or provider identities, health codes linked to individuals, member IDs, or confidential reimbursement data. A qualified reviewer should check the mock records and their wording.
Describe a fictional EOB exercise
Original Fiund exercise
A corrected allowed amount is distinct from a payment or provider bill
An original mock explanation-of-benefits card has generic service labels and arbitrary units. There are no patients, real providers, health codes or claims behind it.
| Record | Source | What it records |
|---|---|---|
| EB1 | EOB version 1 | Service A: billed 100, allowed 70, plan paid 50. Service B: billed 60, allowed 40, plan paid 30. All values practice units. |
| EB2 | EOB correction v2 | Explicitly replaces A's allowed amount with 75. A's billed 100 and plan-paid 50 unchanged; B unchanged. No patient-responsibility field supplied. |
| EB3 | Separate provider card | A statement labeled provider bill lists 45 units but gives no service-line mapping or reconciliation with the EOB. |
Question for the model
What changed in the corrected EOB, and can the packet establish an additional payment or a patient amount due?
Show the reference answer and checks
EB2 changes only service A's allowed amount from 70 to 75 practice units. Its billed and plan-paid fields remain 100 and 50, and service B is unchanged. That five-unit allowed-amount change is not a documented extra payment. EB3 is a different record type with no line mapping, while patient responsibility is absent from the EOB cards. Flag the reconciliation gap rather than calculating a bill or coverage outcome from incomplete fields.
- Calling an allowed-amount adjustment an additional plan payment.
- Treating the EOB as a bill or deriving responsibility from an unexplained provider statement.
Fields to preserve
- Service-line reference and version
- Limits the correction to its target.
- Amount type and value
- Separates billed, allowed and paid figures.
- Record class and missing mapping
- Makes unresolved reconciliation explicit.
Test another case
Add a separate payment confirmation for A, dated later. Require it to be identified as new payment evidence rather than retroactively attributed to EB2.
Use synthetic documents reviewed for terminology. Exclude actual claims, member IDs, confidential reimbursement data and coverage or appeal decisions.
Discuss a contribution
Describe the sources you control, the task they could support and what has already been checked. Use the existing-data assessment for an archive or the collection brief for a new recording project. The contributor agreement defines Fiund’s licensing authority and compensation. A guide or fictional exercise does not establish an accepted collection or a sale.