Explanation of Benefits

Important Information You Should Know About Your Explanation of Benefits Payments Statement

Appeal Rights

For information about an adverse benefit determination, first call your Customer Inquiry area (phone number in top right corner of page 1). To learn more about your appeal rights, visit www.bcbsm.com or call 1-877-354-2583.

Level 1: If you still disagree, you may appeal our decision in writing to the address below the phone number on this statement. Please include your contact and group numbers, daytime phone, patient name, service date, and any documentation supporting your opinion. Include your written authorization if another person will represent you.

Level 2: If you disagree with our first level decision, you may appeal in writing.

At both levels of appeal, we will respond to you in writing. We will complete the appeals process in 35 days and, if our reply at either level is adverse, we will explain any further appeal steps you may have.

If we exceed the time allowed by law or if you disagree with the level 2 decision, you may request an external review from the Office of Financial and Insurance Regulation. If your group self-funds its health care coverage, or if you have Medigap coverage, you aren't eligible for an external review.

Answers to Commonly Asked Questions

Q: How do I report suspect fraud?
A: If you did not receive the services listed on your statement or if you suspect any illegal activity involving BCBSM benefits, please call this toll-free number during regular business hours:
Anti-Fraud Hotline: 1-800-482-3787

You do not have to identify yourself. Only anti-fraud calls are serviced at this number.

Q: How often will I receive a statement?
A: We mail statements once a month to all members who have received health-care services during that time period. When we pay you directly for health-care services received, we send your check and EOB as soon as we process your claim.

Q: How do patient and family deductible and co-payments work?
A: Co-payments and deductibles are the amounts you contribute toward covered services. If your contact requires a deductible or co-payment, we deduct that dollar amount or percentage from the amount we've approved for service. Your contract may also include a patient or family maximum. If it does, we accumulate your deduction during a benefit period until the required maximum has been reached. When you reach the maximum, you are no longer required to pay this portion of the covered service.

Definitions of Statement Terms

Amount above BCBSM's approved amount- The provider's charges that exceed our approved amount. You may be billed for this amount.

Amount approved by BCBSM for this service- Our maximum payment allowed for this service.

BCBSM processed on __and paid__ - This identifies whether BCBSM paid the subscriber or provider for the service and the date the service was processed.

(Total) Charge- The amount that your doctor, hospital, or other health-care professional billed for a service.

Claim Number- The internal number BCBSM assigns to each claim.

Claim Received on- The date BCBSM received the claim.

Co-payment- The portion of BCBSM's approved amount that you must contribute toward your covered health-care services.

Co-payment applied year-to-date- The total that you've accumulated toward your maximum co-payment requirement. (Note: Some services are not applied to the maximum requirement.)

Co-payment required for year- The maximum you must pay toward your health-care services in a benefit year. (Subtract the co-payment applied year-to-date to see how much of your requirements remain.)

(Total) Covered- The total of the amount that BCBSM paid, that other insurance carriers paid, and that your participating providers waived. (You are not responsible for this amount.)

Deductible- The dollar amount that you must contribute toward your health-care services before BCBSM payments begin.

Deductible applied year-to-date- The total dollar amount that you've accumulated toward your maximum requirement.

Deductible required for year- The maximum you must pay before BCBSM begins payments. (Subtract the deductible applied year- to-date to see how much of your requirement remains.)

Other insurance paid- The total of the amounts paid by other insurance carriers, including Medicare, on your behalf.

Participating provider savings- Charges that your provider waived. You saved this amount by using a provider who participates.

Procedure and procedure code- A term and number that BCBSM uses to identify the health- care service performed on your behalf. (You can use this information when you file claims for coordination of other insurance benefits.)

Provider name- The doctor, hospital, or other health-care professional who performed the service.

Provider status- The relationship between your provider and BCBSM. Participation means that your provider works with us to reduce health-care and save you money.

Sanction- The amount you must contribute toward your health-care services if you go to a physician or other provider outside your health plan network or if you do not meet another requirement of your health plan. Your cost is based on the amount we've approved for the service.

Service date- The specific day when each service was performed.

Service type- The category of service provided for the patient.

Your Balance- The total you may owe, which is the sum of all the amounts in bold type. These may include: charges above our approved amount that have not been waived, charges for non-covered services, charges above the contract-allowed maximum, co-payments, deductibles, member liability for X-ray and tests, and sanctions.

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