The world of claims
processing can seem
complicated once you
have your
California health
insurance plan
so let's take a look
at it and shed some
light.
First, the basic
definition of a
claim:
Definition:
A request
for payment by a
medical provider for
a given medical
service or item.
A claim is a request
sent to the
health carrier
to pay for services
to a medical
provider (or
sometimes re-imbursed
to you if you paid
out of pocket) for
cover benefits.
There is usually a
time limit in which
you must submit the
claim in order to
have the carrier
pay. This time
limit can differ
according to the
type of service so
make sure to check
your coverage
information.
Deciphering the
health insurance
claim's EOB or
Explanation of
Benefits
The EOB is the form
you receive from the
carrier for a given
(or multiple)
medical service or
expense incurred.
The EOB will
typically list a
provider (doctor,
hospital, etc), a
date of service, and
then a breakdown of
the costs. The
date of service is
important because
that is how carriers
track various claims
if you have a
dispute. The
tricky part is
usually dissecting
the cost break-down
and item listing.
You usually have the
following items in
the breakdown:
Date of Service
Type of Service
- this is a general
explanation of the
service (sometimes
at a summary level)
Total Amount
-
This the total
charge from the
provider -
comparable to what
you would pay out of
pocket (retail)
Patient Savings
- This is more for
PPO plans where
there is a
discounted PPO rate
you are paying for
coverage benefits,
in-network.
This discount
usually brings down
the total billed
amount 30-60% lower.
Other Amount (or
Amount not allowed)
- This is the amount
typically reflecting
services that are
not covered by the
plan or reflect out
of network
providers.
Applied to
Deductible -
This is an amount
that goes toward the
deductible (if
applicable).
Essentially, you pay
this amount to the
provider.
Coinsurance
amount - This is
the amount you share
with the carrier (as
a percentage once
deductible if any,
is met). Again, this
is the amount you
would pay with the
deductible.
Claims Payment
- This is
the amount the
carrier would pay
the provider.
Somewhere on the
claim, there should
be a total of the
deductible,
coinsurance, and
other amounts which
is what you would
pay the medical
provider. You
will also see a
running total of
your deductible met
to date if
applicable.
Let's look at how
claims processing
differs for
different types of
health plans (HMO
versus PPO for
example)
Claims look quite
differently between
HMO and PPO plans
since the models
operate so
differently.
PPO plans will more
closely reflect the
above EOB.
HMO's do not really
have out-of-network
providers or
coverage (outside of
a true emergency) so
you are less likely
to see the "Other
Amounts" section
completed. You
will probably not
see the Patient
Savings column which
is really a facet of
the PPO model.
Copays are usually
paid in the office
and not reflected on
a claims.
Blue Card for Out of
State members
Blue Card is a
program available to
Anthem Blue Cross or
Blue Shield of
California PPO
members. It
essentially, extends
your benefits to
participating Blue
Cross Blue Shield
providers in other
States. When
seeing a provider in
that other State
(assuming they are
in-network - check
here), the
provider bills the
local BCBS of that
State which then
forwards the claim
through their
nationwide
association to your
local Blue Cross
and/or Blue Shield.
It's pretty seamless
in terms of
processing.
Sequence and timing
of claim's
processing
Claims do not always
arrive in the same
sequence as the date
of services.
Some providers are
quicker at
submitting the
claims. This
will affect the
deductible to date
total listed.
It will also affect
the amount applied
to deductible and
coinsurance.
The key date is when
the claim is
processed as opposed
to when the date of
service was.
Some providers (even
in-network) will
send a bill directly
to you.
Ideally, you do not
want to pay based on
this invoice.
The claim should go
through the carrier,
which will generate
the EOB. If
you pay the first
bill from the
carrier, you will
not know the
discounted PPO rate
if there is one.
Out of network
providers will
send a bill directly
since they do not
route claims through
the carrier.
You would need to
submit a claims form
to get reimbursement
according to your
plan's benefits and
stipulations for out
of network
providers.
In-network providers
should route the
claims directly
through the carrier.
Deductibles and max
out of pockets (when
co-insurance might
end) are typically
calendar year so
they will reset Jan
1st (for dates of
services...not
claims).
Hopefully, this
takes some of the
confusion out of the
claims processing
side of your
California health
insurance plan.
Please let us know
if we can help in
any way.
