Your Health Insurance Claims

When you see a doctor or other health care provider, the provider’s office sends us a claim. The claim includes information on what treatments, tests or other services you received. The claims process is how we determine how much the plan pays and how much you may owe.

We process the claim based on the terms of your specific benefit plan including:

• Your coverage — Is the service included in your benefits? Was it medically necessary? Were any applicable referrals or authorizations in place?
• The allowed amount — We set negotiated rates with network providers. And we process claims based on these amounts.
• Your deductible — This is a set amount you must pay your providers before the plan begins to pay a portion.
• Your coinsurance rate — Once you meet your deductible, the plan generally pays a percentage of the cost. You’re responsible for the remaining amount. For example, the plan may pay 80 percent, while you would pay 20 percent.
• Your out-of-pocket maximum — If you’ve reached your out-of-pocket limit for the benefit year, your plan pays the full allowed amount.

Once we process a claim, we share this information with you in a statement called an Explanation of Benefits, or EOB.

Want to check the status of a pending claim? Or would you like to review your EOBs? With My Health Toolkit^®, you can always access secure information about your claims — any time, from anywhere. Log into to the secure site or download the free mobile app from the App Store or Google Play.