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. The process takes into account:
- 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.
If you’ve recently had medical care, you may wonder about the status of your health insurance claim.
With My Health Toolkit, checking on your claims is easy. On the secure website, look for Health Claims Status under the Benefits tab.
For even more convenience, use the mobile app. You can download it through the App Store or Google Play. To view your claims on the app, select Claims from the menu at the bottom of the page.
Review your EOBs
If we’ve already processed your claim, you’ll be able to review your EOB. Your EOB includes important details about your claim. It includes how much you may owe. It’s always a good idea to compare it to the bill you may receive from your provider.
An EOB is a statement that shows information about how your claim for health care services was processed by us.About Your EOB
There may be times when you’re not sure about a coverage decision and want to talk to us about it. In some cases, you may just need clarity on why we processed a claim a certain way. We're here to help.About Appealing a Claim