“ When you receive an expla- nation of benefits, you should look it over carefully to ensure that 1) it is a valid claim in that you actually did receive the services detailed on it, and 2) that each line item has been properly addressed and paid . . . ”
Retirement and Insurance
If you look closely at the EOB, you will see
9/01/99 in the amount of $52.00.
There is a
$10.00 charge in the “Amount Not Covered” column, which represents the plan’s co-pay- ment of $10.00 as you can see by the RMK (Remark) code of 1. Remarks are usually explained somewhere on the EOB and reading each one can help you better understand how the claim was paid. Co-payments and deductibles don’t generally count towards your
out-of-pocket maximums. The same for expenses in excess of Reasonable
applies & Cus-
tion penalty. (Even in the Indemnity Plan, must notify United Healthcare’s Patient
vocate of any scheduled within 10 days prior to the
hospitalization start of the con-
you could percent.)
On the first line, the charge of $29.00 is reduced by the $10.00 co-payment to a balance of $19.00, which has been paid at 100 percent. The other charges for $14.00 and $9.00 have also been paid at 100 percent. The EOB shows that a total of $42.00 was paid to Dr. Smith, while $10.00 was the patient’s responsibility.
When you receive an explanation of benefits, you should look it over carefully to ensure that 1) it is a valid claim in that you actually did receive the services detailed on it, and 2) that each line item has been properly addressed and paid according to your “Health Benefit Plan for Employees of USAir, Inc. – January 1993” book- let. If you don’t have a copy of this important document detailing all the ins and outs of your coverage, request one from Benefits Adminis- tration at 800-872-4780 and keep it with your important papers.
If you find an item that shows an Item Not Covered, it is often due to the charge being above what is Usual, Customary and Reasonable (UCR). (See US AIRWAVES July, 1998, for full explanation of UCR.) The carrier is only re- sponsible for paying their percentage of UCR. Any amount above that is billable to you as a participant and it does not count toward your deductible or out of pocket maximums. An insurance-wise participant will check with the carrier to see if a provider is charging higher than the normal rates before having services performed whenever possible.
If you find that an item has not been paid at all, the most common reason is “not medically nec- essary.” Remember, you don’t have to accept the amount you are given without a fight! You may appeal ANY and ALL claims and we advise you to do just that. Insurance carriers nowadays are trained to scrutinize claims and try to pay as little as possible. Only the persistent participant (say that twice) gets more money and it’s usually after a few appeals. We’ve seen cases where additional payments of hundreds of dollars are made upon appeal.
How many times can a claim be appealed? You have TWO appeals to United Healthcare and MetLife Dental. You must appeal a claim within 60 days after you receive the EOB. The carrier must respond to you within 90 days of your appeal. On the second appeal, they have another 60 days to respond to you. Once they have rejected your claim (or even partially paid a little more), you have ONE appeal with US Air- ways. US Airways has 60 days to respond to your third appeal.
US AIRWAVES – November/December 1999