Your benefits summary, in very simple words
What to do
- Wait for the bill from your doctor. This paper has no name to pay. It has no due date. So do not pay yet. When the bill comes, look at it. Your part should be about $35.00.
- Does a cost look wrong? Call your plan right away. The number is 1-800-123-4567. Keep the bill. You can ask them to look again.
- Keep this paper in a safe place. Later, you can match it to the bill.
If you do nothing else: your part is $35.00. You pay it only when the doctor's bill comes. Do not pay from this paper.
Where the $35.00 comes from
The doctor first asked for $406.60. Your plan does not pay that full price. Your plan and the doctor agreed on a lower price. That lower price is $120.27.
Here is the math. The doctor asked $406.60. The agreed price is $120.27. Your plan pays most of it. Your part is $35.00. You are not charged the extra.
Your plan paid $85.27 of the agreed price. That $85.27 is for both visits together. You can see each visit below.
See each visit, one by one
| Visit on March 20, 2022 | Agreed price | Your part |
|---|---|---|
| Doctor care, visit 1 | $2.15 | $0.00 |
| Doctor care, visit 2 | $118.12 | $35.00 |
| Both visits | $120.27 | $35.00 |
Visit 1 costs you nothing. Your part there is $0.00. Visit 2 is where your $35.00 comes from.
The agreed price for visit 2 is $118.12. You pay a set part of $35.00. Your plan pays the rest.
Here is the math. $118.12 minus your $35.00 is $83.12. Your plan paid the doctor $83.12 for visit 2.
For visit 1, your plan paid $2.15. So $2.15 plus $83.12 is $85.27. That $85.27 is what your plan paid for both visits.
The set part you pay is called a A set part you pay for a visit. Your plan pays the rest. On your form it is the CoPay column.. Look for it on your form.
What this means
Both visits are marked paid. So your plan has sent its part. Your plan paid $85.27 for both visits. That $85.27 is not your money. You do not pay it back.
Your part is $35.00. That is what is left for you to pay. The $35.00 stands, with one special case. Did you already pay some at the visit? Then you may owe less than $35.00. This paper may not show that yet. The doctor's bill shows the real amount to pay.
Paid more than $35.00 already? Then some money may come back to you. Your form shows who gets it back. That person is the The person who gets money back when a bill is over-paid. On your form it is the Payee box.. On this sample the payee box is blank.
Why $406.60 drops to $120.27. The doctor asked for more than your plan allows. Your plan pays only the agreed price. You are not charged the extra. Your form shows a short note code for this. The code is A short note code on your form. It means the doctor asked for more than the plan allows. So the plan pays only the agreed price..
More detail, if you want it
Every number, both visits
Every number here is from your summary. There are two visits, both on March 20, 2022.
Two more words, both $0.00 here
Your form lists two more money words. Both are $0.00 for these visits. So neither adds to what you pay.
Words on your form, in plain terms
Your form uses these words. Here is what each one means.
If you think a cost is wrong
You can ask your plan to look at a cost again. This is called an A request for your plan to look at a cost again. Use it when you do not agree.. Use this word when you call.
- Call your plan at 1-800-123-4567.
- Do you think you paid for care your plan should cover? Then keep the bill.
- Call right away. Your plan has people who can help.