Prevea360.com/InsuranceTerms For more information, visit
Payments and claims How insurance works
Estimate the cost for a service Check your Member Policy document for details about common medical services. You may also visit Prevea360.com/Members/Cost-Estimator for three tools that estimate physician, facility and pharmacy costs. Explanation of benefits (EOB) The EOB is not a bill. The EOB lists the services used, amount charged by the provider, and your financial responsibility to pay toward deduct- ibles or coinsurance. Sign in to your secure member website to see your past EOBs at Prevea360.com/Login . Submit a claim Claims are usually sent directly to Prevea360 Health Plan by provid- ers or clinics. Sometimes – if you’re traveling out of the area or have a college-age dependent, for example — it may be necessary for you to submit a claim for reimbursement. Visit Prevea360.com and search the phrase: “member paid claim reimbursement form.” Be sure to follow these guidelines: • Send an itemized bill from the provider of service. If services were re- ceived outside of the U.S., you’ll need to submit the original bill along with an itemized bill and indicate the appropriate currency exchange rate at the time the services were received • Send the bill within 60 days (up to 12 months are allowed) after the services are received to: Prevea360 Health Plan, Attn: Claims Department PO Box 56099 • Madison, WI 53705-9399 • If you have another insurance company that is the primary payer, you’ll need to send the Explanation of Benefits to Prevea Health Plan or your health care provider * Not all of the cost-sharing terms listed here apply to all members. Refer to your Member Policy document to understand which apply to you. † Coinsurance is your share of the costs of a covered health care service. It’s calculated as a percent of the allowed amount for the service. For members with PPO and POS Smart Plans and POS Smart Value Choice Plans, coinsurance and copays apply.
It’s our goal to make it as easy as possible for you to understand your financial responsibilities.* Your policy may use a system of cost sharing that can include a copay, coinsurance, deductible, or any combination of the three.
Deductible Each time you receive medical services, you’ll pay the bill for services up to a certain amount. This amount is your deduct- ible, which is your responsibility to pay for covered health care services each year before we begin to pay. Coinsurance† Once you’ve paid the deductible amount, we will then start splitting the cost of additional medical services with you. This is known as coinsurance, meaning you only pay a percentage or part of the total cost of services and we’ll pay the rest. Deductible and coinsurance limit There is a dollar limit to the amount you’ll pay toward your deductible and coinsurance. Copays A copay is a fixed dollar amount, which you pay at the time you receive medical services (for things like an office visit) and prescriptions. All your copays add up toward your maximum out-of-pocket total. Maximum out-of-pocket There’s a dollar limit to all your cost sharing. You reach this amount by means of your deductible, plus your coinsurance, and your copays. Once this limit is reached, you’ll pay nothing on subsequent covered medical charges for the remainder of your policy year. Premium – the amount you pay each month to access your health insurance.
1
2
3
Visit Prevea360.com to find information on your benefits | 9
8 | 2024 Group Member Guide
Made with FlippingBook - Online catalogs