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California health insurance  -  Understand Health Coverage  -  California health plans Claims Processing

A Quick Look at the Claims Process for Most California Health Plans

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:  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:

  1. Date of Service
  2. Type of Service - this is a general explanation of the service (sometimes at a summary level)
  3. Total Amount - This the total charge from the provider - comparable to what you would pay out of pocket (retail)
  4. 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.
  5. 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.
  6. Applied to Deductible - This is an amount that goes toward the deductible (if applicable). Essentially, you pay this amount to the provider.
  7. 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.
  8. 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 (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.

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.
 

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