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  • To get deductible information, including how much has been applied to your deductible and the amount you have left to meet it, follow the steps below once signed in:

    1. Click My Accounts.
    2. Click Out of Pocket Expenses.

    You will be able to view the amount applied to your deductible, as well as your maximum out-of-pocket expenses, by plan member, for a selected benefit period for both in and out of network, as applicable.

    The deductible information displayed is based on the claims that have been processed and finalized as of the date you are viewing the information.

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    Last updated:

    Oct 29,2021

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  • Your Explanation of Benefits (EOB) gives you an overview of the claim, including who provided the care, how much was billed, how much your plan covered, and how much you may owe.

    Sample EOB

    Your EOB gives you detailed information about your claim. It tells you how much you are responsible for paying as a copay, coinsurance or deductible.

    It also lists any “Amount Not Covered,” which may be costs billed by your doctor that are not covered by your plan.

    All of these amounts are included in “What You Owe.”

    Remember: Your EOB is not a bill, so don’t take out your checkbook just yet. Wait until you get a bill from your doctor to pay exactly what you owe.

    You can sign in to view your EOBs, 24/7, or view them with the Horizon Blue app.

    Terms used in an EOB

    1. Date of Service: The date you received your care.
    2. Type of Service: The service or care given to you by the provider.
    3. Amount Billed: The amount charged by the provider for each service on the claim.
    4. Allowed Amount: The amount the provider agrees to be paid for a specific service. It may include a deductible, coinsurance and/or copay.
    5. Your Plan Paid: The total amount paid by Horizon BCBSNJ to you or the provider for the services that were covered by the plan.
    6. Your Other Insurance Paid: The amount paid by another insurance carrier, if you are covered under another health insurance plan.
    7. Copay: A copay is a fee that you pay each time you go to the provider. You pay the copay at the time you receive the care or service.
    8. Coinsurance: The coinsurance is the amount you pay out-of-pocket after you have paid your deductible, if any. You pay the coinsurance amount directly to the provider.
    9. Deductible: The amount you must pay before your plan pays for covered services. You are responsible for paying this amount directly to the provider.
    10. Amount Not Covered: The fee charged for care that is not covered by your plan. You may be responsible for paying this amount in addition to any deductible, coinsurance and/or copay.
    11. What You Owe: The total amount you owe the provider. The total amount includes:
      • Any copay, coinsurance and/or deductible
      • Costs for services you receive that are not covered by your plan
      • The difference between the billed and paid amounts for out-of-network services
    12. Claim Detail: These codes refer to specific messages for each claim that help explain how we processed your claim and calculated any payment.

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    Last updated:

    Jan 09,2022

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  • For information on the specific claims and dollar amounts that have been applied to your deductible and maximum out-of-pocket, sign in and follow the steps below:

    1. Click My Accounts.
    2. Then click Out of Pocket Expenses.
    3. Select the Deductible or Out-of-Pocket Maximum tab.
    4. Select the Benefit Period and click Export to see which claims applied to the deductible and maximum out-of-pocket. Note: You can access this feature from your computer (this option is not available to members on a mobile device such as a smartphone, tablet or notebook).

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    Last updated:

    Oct 29,2021

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  • As our member, you, your duly authorized representative, your doctor or other health care professional acting on your behalf and with your consent, have the right to request an appeal. If you wish to file an appeal, your request should be made in writing and include the following information:

    1. Member name and address
    2. Member ID number
    3. Patient name and address (if different from member)
    4. Provider of service
    5. Date(s) of service
    6. Claim number(s)
    7. Reason for appeal

    Your appeal must be filed within one year of your receipt of the Explanation of Benefits (EOB) statement.

    No member who pursues a right of appeal will be subject to disenrollment, discrimination or penalty by Horizon BCBSNJ.

    For general health claims, except for members of the New Jersey State Health Benefits Program (SHBP), School Employees’ Health Benefits Program (SEHBP), Horizon Blue Medicare Advantage or Medicare Supplement plans, send your appeal to:

    Horizon BCBSNJ
    Attn: Appeals Coordinator
    PO Box 317
    Newark, NJ 07101-0317
    Fax: 1-973-274-4466

    For members enrolled in the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP):

    Please refer to your Member Guidebook for information on how to file an appeal. Your Member Guidebook is available at state.nj.us/treasury/pensions/member-guidebooks.shtml.

    For members enrolled in Horizon Blue Medicare Advantage or Medicare Supplement plans:
    Follow these steps to locate the appropriate appeal information:

    1. Visit HorizonBlue.com/Medicare.
    2. Select Member Quick Links.
    3. Scroll down to Horizon Blue Medicare Supplement Plans and select Additional Plan Documents.
    4. You may need to scroll down to click Appeals & Grievances.

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    Last updated:

    Oct 29,2021

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  • The deductible is the amount of money you have to pay before your health plan starts paying for treatment and services. Sign in to see the claims and dollar amounts that have been applied to your deductible.

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    Last updated:

    Jan 11,2022

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  • There are several reasons a member may be paid instead of the doctor. Usually, this is because the doctor or facility that provided the service, treatment or care does not participate with Horizon BCBSNJ's networks (also referred to as out of network). You will need to send the payment to the provider.

    Remember, when you stay in network you get the most from your benefits and usually pay less out of pocket. Use our Doctor & Hospital Finder to find an in-network (also referred to as participating) doctor, hospital or other health care professional near you. Another reason we may have paid you directly is because claims that process as secondary (meaning the member has other health insurance as primary) will send payment directly to the member.

    In addition, members who send hard copy prescription claims for reimbursement will receive direct payment from Horizon BCBSNJ.

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    Last updated:

    Oct 29,2021

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