Understanding Health Care Claims

A health insurance claim is a formal request, from your doctor, to your Health Plan carrier asking for a payment based on the terms of your insurance policy. The Plan reviews the claim for its validity and then issues a determination based upon the terms of your benefits.   

After your visit, your doctor sends a bill to your Health Plan carrier for charges for the services that were rendered to you.  A claims processor checks the bill for completeness, accuracy and whether the service is covered under your plan.  If the claim determination is approved, the Health Plan issues payment to the provider of services and also sends an explanation of benefits to you.  If the claim determination is denied, the Health Plan issues an explanation to the provider describing the reason for denial of services and sends an explanation of benefits to you.  

An Explanation of Benefits (commonly referred to as an EOB) is a statement sent by your Health Plan carrier providing details on payment for medical services you received. Your EOB is not a bill. An EOB is generated once the Health Plan makes a determination for the claim submitted by your provider. 

 

Here is a sample EOB for your reference.

 

EOBs will tell you how much of the doctor’s charges you are responsible for but is only for your reference. Your medical bill will come from the office which you received services from, not your Health Plan carrier.

What information can you find on an EOB?

Your EOB will contain the following information: 

• The name of the patient
• The Plan Member ID number and claim number
• The name of the health care provider that administered the care
• The type(s) of service you received from that provider and the date(s) of service
• The cost that the provider billed us
• How much of that cost we paid
• Your share of the cost

Your EOB can be used to track what medical services you have received throughout the year and what costs you are responsible for. EOBs can be compared to your medical bills to see if the amount owed matches. If not, you can reach out to your provider for an explanation. 

 

Services from an out-of-network provider are not covered, and providers may bill you for their services. Out-of-Network services are from health care providers and facilities that are not contracted with CHRISTUS Health Plan. A health care provider who is out of your plan network can set a higher cost for a service than providers who are in your health plan network. Depending on the provider, the service could cost more or not be paid for by your plan. Charging this extra amount is called balance billing.

 

Except for emergency services, members who go to an out-of-network provider will have to pay all charges out of pocket for the services they receive. Emergency services are covered whether or not members use an in-network or out-of-network provider or emergency room. (In an emergency, you should go to the nearest emergency room.) Members will pay in-network cost sharing (copayment, coinsurance and deductible) for covered emergency services. 

 

If you ever have questions about what you see on your EOB, please call the Member Services Department at 1-844-282-3026 (TTY 711), 5 days a week,8a.m. to 8p.m. local time.

A denial letter is not a bill.  A denial letter is a communication sent by your Health Plan carrier stating reasons your claim or any part of your claim was denied. The denial letter provides you with information regarding your right to appeal the denial including address and timeline information for appeals.  

For your reference, a sample of Claims Denial Letter can be found here.