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.
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.
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
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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