What is an EOB?

An EOB is an Explanation of Benefits statement detailing your healthcare benefits activity. When we receive a claim filing from your healthcare provider for services rendered, we will adjudicate the claim according to your benefit plan provisions and send you an EOB that details the facility, service date, charges, paid amounts, etc.  An EOB is not a bill or a request for payment.

What is a COB?

Coordination of Benefits is the practice of ensuring that insurance claims are not paid multiple times when an enrollee is covered by two health plans at the same time.  The idea behind coordination of benefits is to ensure that the payments of both plans do not exceed 100% of the covered charges.  The COB determines which plan is primary and which is secondary.  The primary plan will pay the claims first and the unpaid balance will be paid by the secondary plan to the limit of its responsibility. Contact your Human Resources/Benefits Department for the COB form, which is updated annually.  If you are a retiree or on COBRA, you will need to update this form each quarter.

What does Deductible mean?

A deductible is the amount you are responsible to pay for covered services before the insurance plan begins to pay.  Deductibles can be structured with an amount per individual and an amount per family as well as differing amounts for In Network and Out of Network charges.  Refer to the Schedule of Benefits in your Plan Document for details.

What does Schedule of Benefits mean?

A schedule of benefits is a list of the various services covered under a health insurance plan, along with the associated fees. Policyholders receive these schedules so that they know which services and treatments are covered and which are not.

What does Coinsurance mean?

Coinsurance refers to the portion of your healthcare cost for covered services that you are responsible for after the deductible has been met.  The Schedule of Benefits in your Plan Document indicates the percentage at which this health plan will pay for each type of covered service.  Some types of services may not apply to the Maximum Out of Pocket amount.

What does Maximum Out of Pocket mean?

Maximum Out of Pocket is the total amount you will be responsible to pay for covered services in a given plan year as stipulated in the Schedule of Benefits in your Plan Document.  Your Maximum Out of Pocket amount may or may not include deductible or copay amounts.  Some types of services may not apply to the Maximum Out of Pocket.

How do I change personal/dependent information or coverage?

Please consult with your employer's Human Resources/Benefits Department and they will forward the change form to HealthFirst.  Benefit coverage changes due to Qualifying Events must be requested within thirty-one (31) days of the qualifying event.

If I had coverage prior to my effective date, what information do I need to submit for proof of creditable coverage?

Please submit a Certificate of Coverage; you can request this by calling the Customer Service department of your prior insurance carrier.

How do I find out about my medical plan benefits and coverage(s) it provides?

Refer to your Employer's plan document or contact the Customer Service Department at the number indicated on the back of your ID card.

Can I go to a non-network provider?

If you choose to go to a non-participating provider, it may result in a higher out-of-pocket expense, higher deductible, no coverage, etc.  Please refer to your Plan Document for specific information regarding you plan.

Whom should I contact when I have a question regarding a claim?

Contact the Customer Service Department at the number indicated on the back of your ID card.

How long do I have to file a claim?

Please refer to your Plan Document for details regarding claim filing limitations or contact your Human Resources/Benefits Department.

How do I submit a claim for processing?

In most cases, your provider will file the claim directly for you.  If you are filing your own claims, you must submit an itemized statement to the claims mailing address indicated on your ID card. We recommend including receipts with your claims.

Can I appeal a claims determination?

Your Plan Document provides details about appealing an adverse claims determination.  Please contact your Human Resources/Benefits Department.

How do I file an appeal?

It shall be the responsibility of the Claimant or authorized representative to submit an appeal under the provisions of the Plan. Any appeal must include:

  1. The name of the Employee/Claimant.
  2. The Employee/Claimant's social security number.
  3. The group name or identification number.
  4. All facts and theories supporting the claim for benefits.
  5. A statement in clear and consice terms of the reason or reasons for disagreement with the handling of the claim.
  6. Any material or information that the Claimant has which indicates that the Claimant is entitled to benefits under the Plan. 

For Post-service Claims, the file may be submitted in writing and Claimant's appeal must be addressed as follows

Attention: APPEALS
821 ESE LOOP 323 SUITE 200
TYLER, TX 75701

What happens if my Provider or I do not call for pre-certification?

Your Plan has specific non-compliance penalties. See your specific Plan Document for details.

What is the difference between Brand and Generic Drugs?

A brand name drug is protected by a U.S. Patent.  When a patent is no longer valid, any manufacturer can produce the drug under the generic compound name as long as it meets the same FDA testing and standards as the name brand drug.  It is comforting to know that most manufacturers that produce the name brand drug also produce the same drug as a generic. Very often, you are getting the same drug and only the shape or color may be different.

What should I do if my mail order prescription does not arrive in a timely manner?

Your first call should be to the mail order facility that handles the mail order prescriptions for your plan. So please order promptly and make sure that your re-order does have valid refills available. If it does not have refills, you may want to contact the physician for a new prescription.

Don't see the question you need the answer to?  Contact Customer Support at 800.477.2287 or 903.581.2600.