understanding your explanation of benefits (eob) 1
TRANSCRIPT
Understanding your Explanation of Benefits (EOB)
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SERVICE DETAILWhen trying to understand your EOB check the service detail.
Overview
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1. Patient/Relation Claim NumberThe name of the person who received the medical care/relationship of the patient to the employee and the bill reference number (critical to the provider). Multiple patients within the same family may be displayed in alphabetical order.
Patient/Relation claim number
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2. Amount ChargedThe amount the provider charged for the service.
Amount Charged
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3. Not Covered & Less Other BenefitsThe amount, if any, that is not covered. The “Remark Code” section provides additional information as to why charges are not covered.
Not Covered & Less Other Benefits
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4. Amount AllowedThe amount allowable under the benefit plan. This amount is different from number two because the provider and Caterpillar or UnitedHealthcare (UHC) have negotiated a discounted rate for service. Employees will never owe more than the Amount Allowed.
Amount Allowed
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Q/A Q/A
What if my provider is charging me the difference between Amount Allowed and Amount Charged?
The provider has billed you incorrectly. This is referred to as “balance billing”.
Call UHC at: 1-866-228-4215(In this example $1000.00)
Invoice for: Joe Sample
SAMPLE HOSPITAL (provider)
STATEMENT
MEMBER OWES:
$1000.00
All Network providers, by contract, have agreed to charge participants only up to the Amount Allowed.
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5. Copay (see glossary; slide 18)
The amount of the copayment, if any, made by you to a network provider for the service. This applies to your out of pocket expenses.
5. Deductible (see glossary; slide 18)
The amount of the deductible if any, is applied before the plan pays benefits. This amount is the responsibility of the plan member. The deductible will be accumulated in the boxes shown at the bottom of the EOB.
Copay/Deductible
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6. Plan CoversThe percent of the Amount Allowed after copayment/deductible that the plan covers.
Plan Covers
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7. Benefits AvailableThe amount that will be paid to the provider..
Benefits Available
(*) Indicates payment sent directly to providers
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$3000.00 Amount Allowed - $10.00 Copay/Deductible $2990.00 x 100.00% Plan Covers $2990.00 Benefits Available
8. Remark CodeThe code for the explanation of how the claim was processed. Remark code text is listed below the Service Detail box.
Remark Code
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Most common Remark Codes and next steps to understanding your EOB.
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The Remark Codes & Appealing a Claim Process are both available under the “Claims” tab of the CatHealthBenefits site.
9. Plan PaysThe amount of benefits paid to the employee or the provider.
10. Patient PaysThe amount, if any, owed to provider. This may include amounts already paid to your provider at the time of service.
Plan Pays/Patient Pays
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Payment Summary
11.
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This is the total of all claims enlisted on this EOB.
12.
13.
2004
2004
2004
2004
Line 12 Reflects the Deductible and out of Pocket for this claim.
Line 13 is the annual maximum Deductible and Out of Pocket for the current Plan year.
Once the individual or family deductible is satisfied for the calendar year, no additional Deductibles are taken. Copays continue once the individual or family Out of Pocket is satisfied, the plan covers 100 percent except for certain miscellaneous medical expenses and non-network hospital charges. Please see your Summary Plan Description (SPD) for further information. 15
$50.00
$10.00
$100.00 $30.00
$100.00 $30.00
$50.00 $10.00
Q/A
Q/AWhat if I have questions regarding my EOB?
Review your Explanation of Benefits carefully. If you have questions about total charge, amount allowed, plan covers, copay/deductible or any portion of the claim, please contact
UnitedHealthcare’s customer service at 1-866-228-4215.
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Glossary of TermsCopayment – The charge you are required to pay for certain Covered Health Services. A Copayment may be either a set dollar amount or a percentage of Eligible Expenses.
Deductible (shown as “Deduct” on the EOB) – the fixed dollar amount that you must pay each year toward covered medical expenses before your plan benefits are payable.
Explanation of Benefits (EOB) – The statement sent to Participants by their health plan (insurance company or third party plan administrator) that lists services provided, amount billed, payment made for a specific treatment and the claims appeal process.
Network – Used to describe a provider of healthcare services, this means the provider has a participation agreement in effect with the Plan Sponsor (Caterpillar) or an affiliate (directly or indirectly) to provide Covered Health Services for employees, retirees and their dependents.
Out-of-Pocket Maximum – The maximum you pay out of your pocket in a Plan year for certain Copayments for medical care not covered by your insurance plan.
Summary Plan Description (SPD) – A summary of the provisions of an employee benefit plan required by ERISA that must contain certain minimum information including participant rights under ERISA. The SPD must be written so that it is understandable to the average plan participant.
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