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Question: What is an EOB or Explanation of Benefits?
Answer: An explanation of benefits is sent to your home after you have received services from either your doctor, hospital,dentist, etc. This explains to you what benefits were paid from your plan on either yourself or the member of your family that had the services rendered. This is not a bill, and should not be confused with one. You will see the column that states "you pay". That column represents the amount you owe to your doctor, hospital, etc. Always wait however to receive the statement from your provider before paying this amount to your doctor's office etc., to make sure that the amount on your explanation of benefits matches the amount that the providers are billing for. If these amounts do not match, it could mean that the statement you received from your provider's office has included possible previous amounts not paid yet on your account. If this happens then you should call that provider's office to see what the additional amounts are for.
Question: What do I do if I pay my doctor for services in full and then submit my receipt to Benefit Planners and when I get my explanation of benefits back I find that a discount has been taken and I have not been reimbursed the full amount?
Answer: Provider discounts will always be given to the employee when processing their claims. This is the sole reason for PPO plans and network savings. It lowers your out of pocket expense and is a savings to you. However, in these instances when this occurs, you must take your explanation of benefits to your doctor’s office to be reimbursed the overpaid discount from your doctor’s office.
Question: My son/daughter is a full time student, but their claims were denied. What can I do to correct this?
Answer: You must obtain a copy of the registration form from the college your son/daughter is attending for that semester and mail in copy or email to marilynnh@ibatpa.com and we will forward to the Administration department to take care of denied claims and update the eligibility.
Question: What is a Pre-certification?
Answer: Precertification is the process of determining the medical necessity of a non-emergency service in advance of its being performed. Plans specify the services /procedures that require such..
Question: Can you verify if my doctor is in the network?
Answer: You can check the network website for participating providers, or locate the network logo on our website to link directly to the participating network.
Question: I am now eligible for Medicare. Who's plan would be primary?
Answer: If you are still an active employee, then your current employer's plan would be primary over Medicare. However if you are retired and not actively working, then Medicare would be primary. Please note that there are some circumstances that could alter benefits. In these cases you may need to contact your Medicare office.
Question: What is a Pre-Determination letter?
Answer: Pre-determination letters are used to describe the medical or dental services that will be performed before the services are actually rendered. It helps to determine if the services are medically necessary and if they are eligible under the plan.
Question: What is Pre-Existing?
Answer: Pre-Existing means a condition (whether physical or mental) regardless of the cause of the conditions for which medical advice, diagnosis care or treatment was recommended or received within the specified month period ending on the enrollment date.
Question: What is a Pre-Existing exclusion?
Answer: "Pre-Existing Condition Exclusion" means with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care of treatment was recommended or received before such date.
Question: Can you tell me about some common acronyms?
Answer: Here are some of the common acronyms:
- DRG - Diagnosis Related Group
- PA - Third Party Administrator
- EDI - Electronic Data Interchange
- HCFA - Healthcare Finance Administration
- PPO - Preferred Provider Organization
- ICD-9 - International Classification of Diseases 9th edition
- HIPAA - Health Insurance Portability and Accountability Act
- COB - Coordination of Benefits
- NEIC - National Electronic Interchange Corporation
- HCPCS - Healthcare Finance Administration Procedural Coding System
- COBRA - Consolidated Omnibus Budget Reconciliation Act
- CPT - Current Procedural Terminology
- EPO - Exclusive Provider Organization
- ERISA - Employee Retirement Income Security Act
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