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.
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.
You can always run your quote here:
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:
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.
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 is a program available to Anthem Blue Cross (mainly Group now) 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.
You can access the online application here:
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.
Again, there is absolutely no cost to you for our services. Call 800-320-6269 Today!
"My sincere thanks for making a miracle happen- 2014 health insurance !! Many thanks for your expertise and advice yesterday !!"
"Thanks again for your help - I had absolutely no idea how to get this done when I got up this morning. You've made it remarkably easier than I expected. I hope you're not stuck at the office all night..."
"Anyway, I hope you got some time off this past week! Thank you again for your help and efforts on my behalf! I was very lucky to find you."
"I thank you very much for the time that you have invested in handling everything
"I truly appreciate the quick response and will think of you in the future if I need to make any changes to my insurance plans."
"You are awesome... takes a huge worry off my back, thank you for your kind. thanks for your time and kindness. !!"
"Wow, I can't thank you guys enough for your help...I couldn't imagine trying to tackle this on my own!"
"You are my new best friend. A HUGE thank you again.
20 years of experience in the California health insurance market has taught us one thing...Competent and experienced guidance is Invaluable
We can quickly (very important) size up your health insurance needs and clearly explain the options available to you. Our focus is finding the most coverage at the best cost to you.
We are licensed Covered Ca agents with in-depth knowledge of their plans, process, and tax credits.
Call us...you will be Pleasantly Surprised. 800-320-6269
We'll quickly see if you have the best priced plan available and if you qualify for a tax credit800-320-6269
This website is owned and operated by Goodacre Insurance Services, which is solely responsible for its content. This site is not maintained by or associated with Covered California, and Covered California bears no responsibility for its content. The email address and phone numbers that appear throughout the site belong to Goodacre Insurance Services, and cannot be used to contact Covered California.