2013 Billing and Claims
Network providers have contracts with your plan that limit the amount they can bill you for services. Services from these providers cost less than services from non-network providers.
Present your ID card at the time of service. Network providers will submit the claim for you. Non-network providers may request full payment at the time of service, and you may need to file the claim with your plan to be reimbursed. You may file a claim form for the services received within 12 months of the date of service. You can find them on the State Forms page.
After the claim is filed, you will receive an explanation of benefits (EOB) from your medical plan. The EOB is not a bill. It details the service received, the amount covered by the plan and the amount the provider may bill you. The EOB also lists the deductibles and out-of-pocket maximums for your plan. Keep the EOB so you can keep track of your deductible and out-of-pocket balances.
After you receive the EOB, you can expect a bill from the provider. The amount billed should match the amount listed on the EOB. Send payment to the provider. Sometimes you may receive a bill from your provider before you receive the EOB. If this occurs, contact the medical plan before you pay your provider to ensure you’re paying the proper amount.
You will owe the allowed amount charged by each provider until you have met your deductible. After you have paid the deductible amount, the plan begins paying a percentage of the fees charged by providers.
The remaining percentage is your coinsurance. You pay the coinsurance until you reach the plan’s out-of-pocket maximum. After that, the plan pays 100 percent of covered services for the rest of the year.