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Summary Of Health Plan Payments

Below is a sample of the new Summary of Health Plan Payments, this was formerly called Explanation of Benefits. Using feedback from members like you, we created a simpler and easier-to-understand statement that shows how we process your claims and if you owe any balances. This has started going out to our PPO members in March 2013. Members of other plans will receive it later in 2013 and 2014.

This is not a bill. Your doctor or hospital will bill you for any outstanding balances. If you have any questions, please call Member Service at the number on the front of your ID card. You can also view your claims information by creating an account or registering.

Download a PDF Sample

  • Your individual deductible (if you have one) is the amount you pay toward certain covered medical services each year before we start to pay. Your family deductible (if you have one) is the amount you pay before we start paying expenses for the other members on your plan and includes the amount you’ve paid toward your individual deductible. Note: You do not have to pay toward your deductible for certain services, for example, preventive care.
  • This section shows how the adjusted amount charged was calculated.
  • This shows how we processed your claim, so you can see the amount your health care provider(s) charged, the amount we covered, and the amount that’s your responsibility.
  • You'll find the meaning of any unfamiliar terms here.
  • Your most current claim information can be found on Member Central at
  • This section shows recently submitted claim information for your medical services, including dates of services, health care providers, charges, and payment details.
  • The amount of each claim that's your responsibility.
  • Shows how we calculated your financial responsibility per service. The amount depends on whether the service is covered by your plan, if you have met your deductible, and if you have a copayment or co-insurance.
  • You may find additional information on how we processed your claim(s) here.
  • This is the amount you owe toward this claim after we've covered our share. Your health care provider may bill you for this amount. If you have an additional health insurance plan that covers these services, this doesn't apply to you.