# eobs.claims

> The Explanation of Benefits, as a typed schema. An artifact door of the
> api.insure estate, in the health revenue-cycle register, in early access.
> The reference content on this door is free and keyless.

## What this site is

eobs.claims is the reference page for the EOB: the statement a health plan
sends a member after it processes a claim. It defines the document in plain
language, publishes a typed schema for it, and states honestly which parts of
the surface exist today (this reference) and which are roadmap (everything
callable). There is no live parser or API behind this door yet.

Register note, stated honestly: the EOB is a health coverage document, not
property and casualty. This estate serves both registers with one design
system: P&C claim documents (the loss run at lossruns.claims, the loss notice
fields at acords.co) and health revenue-cycle documents like the EOB. Same
typed-schema discipline, different vocabulary, never blurred.

## The document

After a provider bills a health plan, the plan processes the claim and sends
the member an EOB: service line by service line, what was billed, what the
plan's negotiated rate allowed, what the plan paid, and what the member may
owe as copay, coinsurance, or deductible. An EOB is not a bill; any actual
bill comes from the provider. The provider receives the same outcome as an
electronic remittance advice (the X12 835). Every reduction or non-payment
carries a remark code (CARC/RARC, e.g. CO-45 charge over the fee schedule,
CO-97 bundled into another service). If the plan did not cover a line, the
member can appeal; internal appeal windows are commonly 180 days but vary by
plan and state.

## The schema (free, keyless)

Typed shape of a parsed EOB. Full JSON Schema: /openapi.json under
components.schemas.Eob.

- payer (string): the health plan that processed the claim
- member_id (string)
- claim_number (string): the plan's claim identifier; appeals reference it
- provider (string): who rendered and billed the services
- date_processed (date): when the plan finished processing the claim
- lines[].date_of_service (date)
- lines[].procedure_code (string): CPT or HCPCS code
- lines[].billed (money): what the provider charged
- lines[].allowed (money): the plan's negotiated rate
- lines[].plan_paid (money): what the plan paid on the line
- lines[].patient_responsibility (money): copay, coinsurance, or deductible
- lines[].remark_codes (string[]): CARC/RARC codes explaining reductions
- totals (object): billed, allowed, plan paid, patient responsibility
- appeal_window (object): the plan's appeal deadline and address, when stated

## Agent surface (ALL ROADMAP, none callable yet)

- parse: an EOB PDF or 835 remittance in, typed service lines out (ROADMAP)
- reconcile: match the EOB against the provider's bill, flag gaps (ROADMAP)
- explain: turn a remark code into a plain-language sentence (ROADMAP)
- draft: an appeal letter for an uncovered line, deadline attached (ROADMAP)

None of these verbs decides a claim: the plan processes and decides the
claim, and this surface reads the paperwork that decision produces. Drafts
are for a human to review and send. Nothing here is medical, legal, or
billing advice.

## The kit

- /llms.txt: this file (live)
- /openapi.json: OpenAPI 3.1 stub; the Eob schema is real reference content,
  every operation is tagged x-status roadmap and none is callable (live as a document)
- /mcp: FUTURE MCP endpoint, ROADMAP, not live. Planned tools: parse_eob,
  get_eob_schema, explain_remark_code
- /og.png: social card (live)
- /robots.txt: allow-all (live)

## Free tier promise

The discoverability layer is the free tier: this page, the schema, and this
file stay free and keyless.

## Status

Early access. No live service. The document rendered on the page is a
specimen with fictional data; it is not a real plan document and it is not a
bill. Roadmap items are labeled ROADMAP. Contact: hello@api.insure
(subject: eobs.claims early access).

## Links

- https://api.insure (the substrate: the insurance industry as one agent-first API)
- https://gigs.claims (supply side: licensed adjusters)
- https://lossruns.claims (sibling door: the loss run, P&C register)
- https://acords.co (sibling door: loss-notice data fields, P&C register)