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  • Your EOB or Explanation of Benefits 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.

    After you visit a doctor, other health care professional, laboratory or hospital, an EOB is generated for you. If your health care provider participates in Horizon’s networks, the claim is submitted to Horizon for you. But if you go to an out-of-network health care provider, you may need to submit the claim yourself.

    An EOB is not a bill. It tells you what costs are covered for medical care or services you’ve received.

    Understanding Your Explanation of Benefits

    Video Transcript

    [“Understanding Your Explanation of Benefits” title and Horizon Blue Cross Blue Shield of New Jersey logo]

    Each time you use your health plan to get care, you’ll get information about the claim your doctor submitted.

    This information is called an “Explanation of Benefits” or EOB.

    Your 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.

    Your EOB also gives you detailed information about your claim.

    This section lists additional information, including other insurance plan payments, if you have other coverage, and 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 view your EOBs, 24/7, by signing on to HorizonBlue.com or the Horizon Blue app.

    If you have a question about your benefits or your EOB, sign in to HorizonBlue.com to email your question or chat with us, or give us a call. [1-800-355-BLUE (2583)]

    To learn more, visit “What Happens After My Appointment” at HorizonBlue.com. [HorizonBlue.com/AfterMyAppointment]

    [Horizon Blue Cross Blue Shield of New Jersey logo and disclaimer]

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  • A copayment is the fixed amount you must pay after you’ve paid the deductible for each medical visit to a participating doctor or other health care provider, usually at the time of service.

    Understanding Copayments

    Transcript

    Understanding what you pay for your health care is an important part of understanding your coverage.

    Your copayment is a fixed dollar amount you pay each time you get care from your doctor, another type of health care professional or a hospital. Your copayment amount can vary depending on the type of health plan you have and which doctor, specialists or hospital you see.

    Let’s see how a copayment works.

    Sarah has a sore throat and gets an appointment with her in-network family doctor. At the doctor’s office, she pays the copayment amount listed on the front of her member ID card. For Sarah’s plan, the copay is $10 for an in-network family doctor. Once the claim is submitted by her in-network family doctor and processed by Horizon Blue Cross Blue Shield of New Jersey, an Explanation of Benefits statement or EOB is generated. The EOB shows how much her plan paid, how much she paid for her copayment and how much she owes for the visit if applicable.

    What you need to know about copayments?

    Your copayment amounts differ depending on the type of doctor, hospital or other health care professional you visit.

    For example, the copayment to see a specialist in your plan may be higher than the copayment to see your primary care physician. Your copayment may also differ if you go out-of-network. Copayments are one component of your out-of-pocket expenses. Other out-of-pocket expenses may include your coinsurance, annual deductible and the cost for services not covered by your plan.

    Copayments, coinsurance and deductibles: Understanding the differences.

    Your plan could have a copayment, coinsurance or annual deductible. It does not always include all three.

    Copayment. What you pay each time you receive care.

    Coinsurance. What you pay after you’ve met your deductible.

    Deductible. What you pay before your health insurance kicks in.

    What is my maximum out-of-pocket?

    Your maximum out-of-pocket is the highest amount you will have to pay each year. Once you meet your maximum out-of-pocket, your insurance will pay in full for all covered services and you will no longer pay a copayment, coinsurance or a deductible for the remainder of the plan year.

    Maximum out-of-pocket can vary depending on type of plan and the number of dependents covered.

    To learn more about your out-of-pocket costs and your health insurance benefits, visit HorizonBlue.com/understanding-your-costs.

    If you need help finding information about your benefits, claim status and more, sign in to our secure Member Online Services at HorizonBlue.com to: read our FAQs, send us a question through our secure email or ask a question through Chat during normal business hours.

    Horizon Blue Cross Blue Shield of New Jersey remains committed to helping you understand your benefits.

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    Jan 07,2022

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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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  • Coinsurance is the percentage you pay for a covered medical treatment or service after you’ve paid your deductible. The amount of your coinsurance depends on the type of medical care or service you receive and your specific plan. It is usually shown as a percentage of the overall cost of the service or treatment.

    Understanding Coinsurance

    Transcript

    Understanding what you pay for your health care is an important part of understanding your coverage.

    This short video explains what coinsurance is and how it works.

    Let’s get started.

    What is coinsurance? Coinsurance is the percentage you pay for a covered medical treatment or service after you’ve paid your deductible. The amount of your coinsurance depends on the type of medical care or service you receive and your specific plan. It is usually shown as a percentage of the overall cost of the service or treatment.

    Here’s how it works.

    John goes to the doctor to treat his strep throat and has a coinsurance of 20% when seeing his in-network primary care physician. John’s insurance has a $100 allowed amount for this type of in-network doctor’s office visit. Since John has a plan with a 20% coinsurance, John has to pay 20% of the $100 charge for his office visit OR $20. His insurance plan pays the rest OR $80.

    Deductibles, coinsurance and copayments – understanding the differences.

    Your plan can have an annual deductible, coinsurance and/or a copayment. It does not always include all three.

    An annual deductible is the amount you have to pay during one benefit year before your health insurance starts paying for eligible medical treatment and services. 

    Coinsurance is the percentage of the costs for covered care that you have to pay.

    Your copayment is the set amount you pay each time you receive care for a covered benefit. If your plan includes a copayment for services, it will not include a coinsurance for the same service type.

    What is my maximum out-of-pocket?

    Your maximum out-of-pocket is the highest amount you will have to pay each year. Once you meet your maximum out-of-pocket, your insurance will pay in full for all covered services and you will no longer pay a copayment, deductible or coinsurance for the remainder of the plan year.

    To learn more about your copayment, deductible and coinsurance, sign into Member Online Services at HorizonBlue.com.

    Need more help?

    If you need help finding information about your benefits, claim status and more, sign into our secure Member Online Services on HorizonBlue.com to: read our FAQs, send us a question through our secure email OR ask a question through Live Chat.

    Horizon Blue Cross Blue Shield of New Jersey remains committed to helping you understand your benefits.

    Thank you for watching.

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  • You received a check for the payment of services provided by an out-of-network doctor or other health care professional. The check was attached to the Explanation of Benefits (EOB) for that service. You should:

    1. Deposit the check into your personal account.
    2. After you receive the doctor's bill, pay them directly from your personal account. This amount should be for the same amount as the check you received from Horizon.

    If the amount of the check you received from Horizon and the doctor's bill does not match, email us or chat with a Member Services Representative.

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  • Please call Horizon BCBSNJ’s Member Services phone number on the back of your member ID card to get a copy of a cashed check or ask for an outstanding check to be reissued.

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