Western PA/Susquehanna Member Guide

Three ways you can find the out-of-pocket costs for your plan: 1. Look on your member ID card. It will tell you copay and coinsurance amounts for some common services. 2. After logging in to My Health OnLine, go to the Your Insurance section of the homepage. Click Plans and Coverage. Then, click on the Medical banner. The What is covered? dropdown includes details about your coverage and important plan documents. 3. For more detailed information, see the Evidence of Coverage for your plan. You can call your Health Care Concierge team to have a copy mailed to you at any time. Explanation of Benefits After doctor or hospital visits, you’ll receive an Explanation of Benefits (EOB) that tells you the cost of care and whether you are responsible for a copay, deductible, coinsurance, or any other balance. The EOB also indicates whether your claim was denied and the reason(s) for the denial. EOBs make it easy to track when you reach your deductible (if applicable) and exactly what you pay for certain services. Here’s how the claims process works: 1. After you receive care, your provider sends UPMC for Life a claim. 2. We process your claim based on your specific plan benefits. 3. We get back to your provider with how much we will pay and what you will owe your doctor (if anything). 4. We send you an EOB as claims are processed as well as on a quarterly basis. This summarizes how we processed your claims and what you may owe your providers. Your EOB is not a bill. You do not pay anything to anyone when you receive your EOB. 5. If you owe your provider money, they will send you a bill. 15 Get your EOB electronically. Here’s how: Log in to My Health OnLine > Menu > Preferences.