Calculation of Your Out-of-Pocket Cost

www.MPIPHP.org
Los Angeles, CA 90000
Calculation of Your
Out-of-Pocket Cost
You have two potential categories of responsibility
for your health benefits, if you use an
in-network provider.
•Your Co-payment: the dollar amount you are
expected to pay directly to the provider at the
time of service.
•Your Co-insurance: the percentage of total coverage
for which you are responsible. You will be billed
for that amount by the provider.
You may have additional costs if you use an
out-of-network provider or receive services that are
not fully covered.
When a medical service or procedure requires both
a co-payment and co-insurance, MPI applies your
co-insurance first, then your co-payment. The example
below assumes you’re admitted to a participating
hospital for a two-day stay. Your MPI benefit
pays 90% of the “allowed” amount for a contracting
provider, less a co-payment of $100. Although the
allowed amount is likely less than the contracted
provider’s actual charges, the provider has agreed
to accept the allowed amount as payment in full.
(See example below.)
Benefit Calculation Example
Hospital Inpatient Charge
$ 3,200
Participating Provider Discount -$ 500
Allowed Amount
Participant Co-insurance
(10% of allowable)
Balance Due
$ 2,700
-$270
$ 2,430
Less Participant Co-payment - $100
MPI Paid Amount
$2,330
In the example above, you would pay a $100
co-payment plus the 10% co-insurance for a total
Participant responsibility of $370. Remember that your
EOB is not a bill. Your provider will bill you directly.
Use Your EOBs for Comparison
Please keep your EOBs so you can compare your
provider’s bills with your EOB statements before
you send payment to the provider. This could help
you identify any inaccurate billings and save you from
paying more than your fair share.
Check the status of your claims
or view and print your EOBs
For Participants Covered by the MPI Anthem Blue Cross Preferred Provider Option (PPO)
How to Read Your Explanation of Benefits
EXPLANATION OF BENEFITS – This is NOT a Bill
This document contains important information that you should retain for your records.
CLAIM INFORMATION
Patient Name:
Claim No:
Provider Name:
FROM
TO
09/26/12
09/27/12
1
Sarah Jones
12331E07762
XYZ Hospital
Date of Service
2
SERVICE
Hospital Services
SVC
CDE
0120
TOTALS
CHARGED
AMOUNT
EXCLUDED
AMOUNT
RSN
CDE
3200.00
0.00
F12
$3200.00
$0.00
PAYEE: XYZ Hospital
AMOUNT PAID BY MPI: $2330.00
Patient Responsibility
Line #
001
Co-Pay
Co-Insurance
$100.00
1 MPI Identifying Information
$270.00
PARTICIPANT NAME
5
Non Covered
Amount
$0.00
4
John Smith
CLAIM PROCESS DATE
1/29/13
PROVIDER
DISCOUNT
ALLOWED
AMOUNT
DEDUCT
CO-PAY/CO-IN
500.00
2700.00
370.00
0.00
2330.00
$500.00
$2700.00
$370.00
0
$0.00
$
$2330.00
Out of Pocket Maximum
This Claim: $270.00
Year to Date: $527.19
3
F12
RSN Description
Provider Write off
3 How MPI Processed Your Claim
PAYMENT
AMOUNT
PATIENT RESPONSIBILITY
$370.00
Denial Reason
RSN Code
COB
4
5
Amounts Due to the Provider
•Participant Information – MPI Participant’s name and
the name of the covered patient.
•Charged Amount – The amount your provider billed
for the service(s).
•Payee – The entity, organization, provider or Participant
receiving payment for rendered care.
•Claim Number – The number assigned to a single
service or series of services. Have this number handy if
you contact MPI.
•Excluded Amount – The amount not covered by
your plan and, therefore, your responsibility.
•Amount Paid on Claim by MPI – The benefit amount,
minus what any other insurance paid (if applicable) and
minus your patient payment responsibility.
•Claim Process Date – The date MPI issued the EOB.
•Provider Name – The provider or organization that
rendered the care.
2 Services Provided to You
•Date of Service – The date or range of dates on which
you received services from the provider.
•Service – Brief description of the type of service
provided.
•Service Code (SVC) - Your health care provider
assigns codes based on industry standards for
designated procedures.
•RSN Code – A code that indicates the reason for an
excluded amount. (Refer to the Denial Reason section
for details.)
•Provider Discount – The discount for providers who
have a contract with the insurer (Anthem Blue Cross
Network providers).
•Allowed Amount – The maximum amount the Plan
pays for a covered service.
•Deduct Co-pay/Co-in – This abbreviation stands for
Deducted Co-payment/Co-insurance.
•COB – This is an abbreviation for Coordination of
Benefits and is applicable only if you are also
covered by another insurance plan. It indicates the
amount paid by that plan.
•Payment Amount – The actual amount your
provider charged, minus the excluded amount and/or
co-payment/co-insurance/provider discount.
•Out-of-pocket Maximum – The maximum amount
of in-network charges that you must pay for this
particular claim (excluding co-payments). Includes a
running, annual tally.
•Patient Responsibility – The amount you owe the
provider, based on the information available when
the claim was processed. This amount includes any
co-payments, co-insurance and excluded charges.
5 Additional Detail
•Patient Responsibility Break Down – Shows a line-byline service code assignment of costs that add up to the
total patient responsibility.
•Denial Reason – The explanation for why a claim was
not paid in-full.