Your Explanation of Benefits, or EOB, contains a Patient’s Responsibility after payments 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.
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 typically require a copay. You will not be reimbursed for this amount.
A deductible is the amount you pay for covered services before your plan starts to pay.
Coinsurance is the amount, calculated as a percentage, 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. The total amount of coinsurance that you must pay is limited per benefit year. Check with your employer for your plan’s rules.
For covered services from PPO providers, the allowable charge is the billed amount or the billed amount less the PPO discount. For covered services from non-PPO providers, the allowable charge is determined by the plan. An example of an allowable charge for non-PPO provider covered services is a percentage of the Medicare allowed charge. Consult your plan document for more information.
Claim forms are not usually required to submit medical claims to Significa Benefit Services. PPO providers submit your medical claims directly to us. For claims from non-PPO providers, you can down load a claim form from here.
For Flexible Spending Arrangement and Health Reimbursement Arrangement claims, you can obtain the necessary claim form from your HR Department or download it from here.
Generally, a "clean" claim (a medical claim that does not require investigation and contains all necessary information for adjudication) is processed within 10 days from the date it is received. Non-medical claims such as dental, vision, Health Reimbursement Arrangement and Flexible Spending Arrangement are processed generally within five days.
If you or your covered dependents have coverage under more than one benefit plan, Significa Benefit Services must determine which plan pays first, second etc. To do this, we request that you complete the "Request for Duplicate Coverage" form on an annual basis.
An accident form provides detail regarding medical charges and services resulting from accidental injury or illness. For example, this form provides information about where the accident occurred and helps to identify charges that may be the responsibility of another party.