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What Happens After My Appointment?

It’s important to know what will happen after you get care.

Who submits the claim?
Generally, when you go to a participating doctor, other health care professional, laboratory or hospital, the claim is submitted to Horizon BCBSNJ for you. If additional information is required, we will contact your doctor or hospital directly. If you go to an out-of-network doctor, other health care professional or hospital, you may be responsible to submit the claim.

Once the claim is received and processed, an Explanation of Benefits (EOB) statement is generated and can be viewed and printed by signing in. One EOB may include information about more than one claim for you or a covered dependent.

Explanation of Benefits (EOB) and what it means
Each time a claim is processed, Horizon BCBSNJ generates an EOB statement. The EOB gives you important information about the claim, including:

  • The amount your plan allows for the treatment, service or device
  • How much your plan paid
  • How much you owe, if applicable

Refer to the sample below for an overview of what is included on an EOB or watch this short video to learn more about what the information in an EOB means.

To view or print your EOB, simply sign in and click Claims. From there you can review your recent claims and filter by the covered members under your plan, claim type, claim number and more. If you register for paperless EOBs, you will get an email each time an EOB is ready online.

A – Date of Service: The date that services were provided.

B – Type of Service: A brief explanation of each service your doctor or other health care professional provided.

C – Billed Amount: The amount charged by the doctor, health care professional or facility for each service on the claim.

D – Allowed Amount: The total amount Horizon BCBSNJ allows the doctor or hospital to be paid for a particular service. This amount may be different from the Billed Amount. It also may include the deductible, coinsurance or copayment that you owe.

E – Your Coinsurance/Copayment Amount: The coinsurance or copayment is the amount you must pay out of pocket after you have met your deductible, if this applies to your plan. You pay this amount directly to the doctor or hospital. Generally, you pay the copayment at the time you received the care or service.

F – Your Deductible Amount: The amount you must pay to meet your annual deductible before your plan pays for covered services. You are responsible to pay this amount directly to the doctor or facility. Please make sure you match the EOB to the bill you receive from the doctor, other health care professional or facility. Not all plans or services within a plan include a deductible.

G – Other Carrier Payment Amount: The amount paid by another insurance carrier, if you have additional health insurance.

H – Not Covered Amount: Any amount of the fee charged for a service that is not covered by your plan. You may be responsible to pay this amount in addition to any deductible, coinsurance or copayment, if applicable. When using an out-of-network doctor, health care professional or facility, the costs above the negotiated rate of an in-network provider will appear here.

I – Horizon BCBSNJ Paid Amount: The total amount paid by Horizon BCBSNJ to you, your doctor or hospital for the covered services performed.

J – Message Code: These codes refer to specific messages for each claim that help explain how we processed your claim and calculated the payment, if applicable.

K – Subscriber Responsibility: The total amount you owe the doctor, other health care professional or hospital/facility. This includes any copayment, coinsurance and/or deductible, if applicable, and any costs for non-covered services you receive. For out-of-network services, the difference between the billed and paid amounts is included here. In-network doctors and hospitals are not allowed to bill you the difference for covered services.

Coinsurance, copayment and deductible. What’s the difference?
Depending on your plan, you may have to pay a coinsurance, copayment and/or meet a deductible. Watch our videos for an explanation on each. Then check your plan documents to see which applies to you.

What if my doctor sends me a bill?
If your doctor or hospital sends you a bill, check your EOB. Your EOB will explain what your plan paid and how much you owe, if applicable. In-network doctors and hospitals cannot charge you for anything other than your copayment, coinsurance and/or deductible for covered services.