Your benefits summary, in plain words
What to do next
- Wait for the bill from your provider. This page does not name a payee or a due date, so do not pay anything from it. When the provider's bill comes, check that your share on it is about $35.00.
- If a charge looks wrong, call your plan right away at 1-800-123-4567 and keep the bill. You may be able to appeal a payment decision you disagree with.
- Keep this summary with your paperwork so you can match it to the bill later.
If you do nothing else: your share is $35.00, and you pay it only when the provider's bill arrives, not from this page.
Where the $35.00 comes from
Your provider first billed $406.60 for both visits. Your plan does not pay the billed price; it pays the lower allowed price it agreed with your provider. Your share is worked out from that allowed price, not the billed price. Your plan paid $85.27 straight to your provider, and your share is $35.00.
Show each visit, line by line
| Visit on March 20, 2022 | Allowed price | Your share |
|---|---|---|
| Medical care (line 1) | $2.15 | $0.00 |
| Medical care (line 2) | $118.12 | $35.00 |
| Total | $120.27 | $35.00 |
The the amount your plan and provider agree the care is worth; your plan pays only up to this, and you are not charged the difference is what your plan and provider agreed the care is worth. Your provider billed more ($406.60), but your plan pays only the allowed price. Your share of the second visit is a $35.00 a set amount you pay for a covered service; your plan pays the rest of the allowed price.
Here is the math for the second visit: the allowed price ($118.12) minus your copay ($35.00) equals what your plan paid the doctor ($83.12). Your copay is your $35.00 share.
What this means
Both visits show a status of paid, so your plan has already sent its part ($85.27) to your provider. The the amount your health plan pays straight to your provider amount does not come out of your pocket.
Your $35.00 share is what is left after your plan paid its part. You may have already paid some of it at the visit. If you paid your provider directly, that amount may not be taken off this summary yet, so the provider's bill is what shows the final amount to pay.
Already paid more than $35.00 at the office? If you overpaid, the money back goes to the the person your plan lists to receive money back for over-paying a claim shown on your summary. On this sample the payee is blank, so your own summary is what names who gets the refund.
Why the big drop from $406.60 to $120.27: the note on this summary (code a remark code from your plan. PDC means the billed amount is higher than the most the plan allows, so the plan pays only the allowed amount) says your provider billed more than the most your plan allows. Your plan pays only the agreed price, and you are not charged the difference.
More detail, if you want it
Full claim detail, both visits
Every figure below is copied from your summary. Line 1 and line 2 are the two visits on March 20, 2022.
Your summary also lists a what you pay each year for care before your plan starts paying its share and a share of a cost you pay as a percent, after you meet your deductible. Both are $0.00 for these visits, so neither adds to what you owe.
Words on your summary, in plain terms
Your right to appeal
If you disagree with a coverage or payment decision by your plan, you may be able to appeal it.
- Call your plan at 1-800-123-4567.
- If you think you were charged for care your coverage should pay for, keep the bill.
- Call right away. Plans have call and support centers to help.