www.MPIPHP.org Los Angeles, CA 90000 Calculation of Your Out-of-Pocket Cost You have two potential categories of responsibility for your health benefits, if you use an in-network provider. •Your Co-payment: the dollar amount you are expected to pay directly to the provider at the time of service. •Your Co-insurance: the percentage of total coverage for which you are responsible. You will be billed for that amount by the provider. You may have additional costs if you use an out-of-network provider or receive services that are not fully covered. When a medical service or procedure requires both a co-payment and co-insurance, MPI applies your co-insurance first, then your co-payment. The example below assumes you’re admitted to a participating hospital for a two-day stay. Your MPI benefit pays 90% of the “allowed” amount for a contracting provider, less a co-payment of $100. Although the allowed amount is likely less than the contracted provider’s actual charges, the provider has agreed to accept the allowed amount as payment in full. (See example below.) Benefit Calculation Example Hospital Inpatient Charge $ 3,200 Participating Provider Discount -$ 500 Allowed Amount Participant Co-insurance (10% of allowable) Balance Due $ 2,700 -$270 $ 2,430 Less Participant Co-payment - $100 MPI Paid Amount $2,330 In the example above, you would pay a $100 co-payment plus the 10% co-insurance for a total Participant responsibility of $370. Remember that your EOB is not a bill. Your provider will bill you directly. Use Your EOBs for Comparison Please keep your EOBs so you can compare your provider’s bills with your EOB statements before you send payment to the provider. This could help you identify any inaccurate billings and save you from paying more than your fair share. Check the status of your claims or view and print your EOBs For Participants Covered by the MPI Anthem Blue Cross Preferred Provider Option (PPO) How to Read Your Explanation of Benefits EXPLANATION OF BENEFITS – This is NOT a Bill This document contains important information that you should retain for your records. CLAIM INFORMATION Patient Name: Claim No: Provider Name: FROM TO 09/26/12 09/27/12 1 Sarah Jones 12331E07762 XYZ Hospital Date of Service 2 SERVICE Hospital Services SVC CDE 0120 TOTALS CHARGED AMOUNT EXCLUDED AMOUNT RSN CDE 3200.00 0.00 F12 $3200.00 $0.00 PAYEE: XYZ Hospital AMOUNT PAID BY MPI: $2330.00 Patient Responsibility Line # 001 Co-Pay Co-Insurance $100.00 1 MPI Identifying Information $270.00 PARTICIPANT NAME 5 Non Covered Amount $0.00 4 John Smith CLAIM PROCESS DATE 1/29/13 PROVIDER DISCOUNT ALLOWED AMOUNT DEDUCT CO-PAY/CO-IN 500.00 2700.00 370.00 0.00 2330.00 $500.00 $2700.00 $370.00 0 $0.00 $ $2330.00 Out of Pocket Maximum This Claim: $270.00 Year to Date: $527.19 3 F12 RSN Description Provider Write off 3 How MPI Processed Your Claim PAYMENT AMOUNT PATIENT RESPONSIBILITY $370.00 Denial Reason RSN Code COB 4 5 Amounts Due to the Provider •Participant Information – MPI Participant’s name and the name of the covered patient. •Charged Amount – The amount your provider billed for the service(s). •Payee – The entity, organization, provider or Participant receiving payment for rendered care. •Claim Number – The number assigned to a single service or series of services. Have this number handy if you contact MPI. •Excluded Amount – The amount not covered by your plan and, therefore, your responsibility. •Amount Paid on Claim by MPI – The benefit amount, minus what any other insurance paid (if applicable) and minus your patient payment responsibility. •Claim Process Date – The date MPI issued the EOB. •Provider Name – The provider or organization that rendered the care. 2 Services Provided to You •Date of Service – The date or range of dates on which you received services from the provider. •Service – Brief description of the type of service provided. •Service Code (SVC) - Your health care provider assigns codes based on industry standards for designated procedures. •RSN Code – A code that indicates the reason for an excluded amount. (Refer to the Denial Reason section for details.) •Provider Discount – The discount for providers who have a contract with the insurer (Anthem Blue Cross Network providers). •Allowed Amount – The maximum amount the Plan pays for a covered service. •Deduct Co-pay/Co-in – This abbreviation stands for Deducted Co-payment/Co-insurance. •COB – This is an abbreviation for Coordination of Benefits and is applicable only if you are also covered by another insurance plan. It indicates the amount paid by that plan. •Payment Amount – The actual amount your provider charged, minus the excluded amount and/or co-payment/co-insurance/provider discount. •Out-of-pocket Maximum – The maximum amount of in-network charges that you must pay for this particular claim (excluding co-payments). Includes a running, annual tally. •Patient Responsibility – The amount you owe the provider, based on the information available when the claim was processed. This amount includes any co-payments, co-insurance and excluded charges. 5 Additional Detail •Patient Responsibility Break Down – Shows a line-byline service code assignment of costs that add up to the total patient responsibility. •Denial Reason – The explanation for why a claim was not paid in-full.