Questions about a bill or coverage decision?

What brought you here?

• A bill I do not understand. Compare the provider’s bill with the plan’s explanation of benefits and ask for an itemized explanation.
• A coverage decision I disagree with. Find the written decision, its stated reason and the plan’s appeal instructions.
• A directory entry that seems inaccurate. Keep a dated copy of what the directory showed and a factual record of the contact attempt.

A bill is not an explanation of benefits.

A provider’s bill requests payment. An explanation of benefits, often called an EOB, describes how your plan processed a claim. Compare service dates, billed charges, allowed amounts, plan payments and any stated patient responsibility. Ask about differences before assuming either document is correct.

Gather the records you already have.

• Bill and explanation of benefits.
• Coverage or denial notice and plan booklet.
• Dated notes of contacts and any written responses.
• Directory evidence, if relevant. Keep original records securely.

Complaint or appeal?

An appeal asks for a benefit or payment decision to be reconsidered. A complaint raises a concern about a process, service or conduct. They can serve different purposes. A complaint does not automatically preserve an appeal deadline. Check the plan documents and decision notice.

A few useful terms.

• Allowed amount: the amount recognized under the plan for a service.
• Deductible: an amount you may pay before certain plan benefits begin.
• Administrator: an organization that handles tasks such as processing claims for a plan.
• Self-funded plan: a plan in which an employer funds benefits and may hire an administrator. The logo on an ID card alone does not establish the plan category.