About Your Claims
Each time LifeWise processes a claim submitted by you or your healthcare provider, we explain how we processed it in the form of an Explanation of Benefits (EOB).
The EOB is not a bill. It simply explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid and any balance you're responsible for paying the provider. It also tells you how much has been credited toward any required deductible. (We recommend you keep all EOBs for at least two years.)
Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider. To help in this task, we've explained the EOB form, item by item.
Now the EOB is Easier to Read, Understand and Use
There's a lot of information packed into the EOB. We re-organized it all so you can quickly find what matters most to you. The new EOB contains 3 items:
• A Claim Summary page that explains costs and claim detail using simple math. Now you'll clearly know how much you owe a provider, how much you've paid on your deductible, and how much you saved as our member.
• An easy-to-use glossary page to help you understand health coverage terms.
• An updated EOB Claim Detail page (shown below). This should be used to confirm bills from your provider. It uses medical descriptions that make sense, so you don't have to pull out a dictionary to figure them out.
How to Read the Updated EOB Claim Detail
We've explained the EOB item by item below to help you confirm bills from your provider see how much of your own money you spent, and decide where you may be able to save money in the future.
EOB Key
- Explanation of Benefits (EOB) - A claims statement that is sent whenever you use your health plan for services or products from a healthcare provider. It shows how your benefits cover the cost of a service from your provider and what you owe. The EOB is not a bill.
- Service/Product - The type of services or products you received from your provider.
- Dates of Service - The date(s) you received service.
- Amount Billed - The full amount billed by your provider to your health plan.
- Your Plan Discounts & Payments - This section details the amounts that you do not need to pay.
- LifeWise Network Discount - The amount you save by using a provider that belongs to a LifeWise network. LifeWise negotiates lower rates with its in-network providers to help you save money. This amount may not be itemized and may only show in the Totals row of the Claim Detail.
- Amount Paid By Your Health Plan - The portion of the charges eligible for benefits minus your copay, deductible, coinsurance, network discount and amount paid by another source up to the billed amount.
- Amount Paid By Another Source - Examples of other sources include: a health funding account, other health insurance, automobile insurance, homeowners' insurance, disability insurance, etc. This amount may not be itemized and may only show in the Totals row of the Claim Detail.
- Copay - A set amount you pay for certain covered services such as office visits or prescriptions. Copays are usually paid at the time of service.
- Deductible - Your deductible is the amount you need to pay each year for covered services before your plan starts paying benefits.
- Coinsurance - A percentage of covered expenses that you pay after you meet your deductible.
- Amount Not Covered - The portion of the amount billed that was not covered or eligible for payment under your plan. Examples include charges for services or products that are not covered by your plan, duplicate claims that are not your responsibility, amount related to not getting a prior authorization for service, and any charges submitted that are above the maximum amount your plan pays for out-of-network care.
- Your Total Responsibility - This section details the portion of the bill that is your responsibility to pay. This amount might include your copay, deductible, coinsurance, any amount over the maximum reimbursable charge, or products/services not covered by your plan. If you received payment intended for a provider, it is your responsibility to pay the provider.
- Claim Notes - When present, these notes provide general information about the claim and may also provide specific explanation of activity that occurred in the Amount Not Covered, Amount Paid by Another Source, and What Your Plan Paid fields. For example, if the claim was denied because your provider submitted the same claim twice, a note would tell you that we denied the claim as a duplicate.
- Benefit Booklet Information - If applicable, contains information about why portions of a claim were denied.