Frequently Asked Questions: Health Insurance

What is "Patient’s Responsibility" on the Explanation of Benefits Statement?

Your Explanation of Benefits, or EOB, contains a Patient’s Responsibility box. The total of deductible, coinsurance, copayments and amounts not covered by your plan are shown in this box. These are your "Out-of-Pocket" expenses. You should contact your medical provider to confirm your actual payment amount due before paying the amount shown in this box.

What is a Copay?

A copayment, or copay, is the amount you must pay to your medical provider at the time of service. Office visits, emergency room visits and prescription drugs normally require a copay. You will not be reimbursed for this amount.

What is a Deductible?

Most deductibles are "annual" deductibles. An annual deductible is the amount of covered expenses you must pay before your benefit reimbursements begin each year.

What is Coinsurance?

Coinsurance is the amount that you must contribute towards payment of each claim to a maximum amount. For example, if the coinsurance under your plan is 80 percent, you would be required to pay 20 percent of the eligible claim expense. Some plans limit the total amount of coinsurance that you must pay within a year. Check with your employer for your plan’s rules.

What is UCR?

UCR stands for usual, customary and reasonable charges. A charge is considered reasonable if it is not higher than the amount typically billed by similar providers within the same area for similar services. Generally, if you are in a PPO network and obtain services from a provider that is a member of your PPO network, UCR does not apply

Where can I get a PPO directory?

The PPO network web site allows you to locate providers based on location, specialty and other options. You can link to these PPO web sites from our web site using the PPO Links page. (Read our Privacy Policy.)

Must I submit a claim form to receive benefits?

Claim forms are not usually required to submit a claim to Significa Benefit Services. PPO providers submit your claims to us at the address on the back of your ID card. For some claims, additional information is required to correctly process the claim. Forms used for providing this information can be found on the Forms page of Significa Benefit Services’ web site. If you wish to submit a claim, you can download the claim form from the forms library.

How long does it take to process a claim?

Generally, a "clean" claim (a claim that does not require investigation and contains all necessary information for adjudication) is processed within 10 days from date recevied.

Why must I complete a "Duplicate Coverage" form on an annual basis?

To assure benefit reimbursements are paid in the correct order, we verify dependent "other coverage" status on an annual basis.

What is an accident form and why is this information necessary?

An accident form provides detail regarding a claim, for example, where the accident occurred and helps to identify services that may be the liability of another party.