What is "Patient’s Responsibility" on the Explanation of Benefits Statement?

Your Explanation of Benefits, or EOB, contains a Patient’s Responsibility box. The total of all deductible, coinsurance, copayments and amounts not covered by your plan are shown in this box. These are your "Out-of-Pocket" expenses. You should contact your medical provider to confirm your actual payment amount due before paying the amount shown in this box.

What is a Copay?

A copayment, or copay, is the amount you must pay to your medical provider at the time of service. Office visits, emergency room visits and prescription drugs normally require a copay. You will not be reimbursed for this amount.

What is a Deductible?

Most deductibles are "annual" deductibles. An annual deductible is the amount of covered expenses you must pay before your insurance benefits begin each year. Some plans may allow amounts from the end of a year, typically October 1 and later, to be applied to the next year’s deductible. Check with your employer for your plan’s rules.

What is Coinsurance?

Coinsurance is the amount that you must contribute towards payment of each claim to which the coinsurance applies. For example, if the coinsurance under your plan is 80 percent, you would be required to pay 20 percent of a claim expense, while your insurance benefits would cover the other 80 percent. Some plans limit the total amount of coinsurance that you must pay within a year. Check with your employer for your plan’s rules.

What is UCR?

UCR stands for usual, customary and reasonable charges. A charge is considered reasonable if it is not higher than the amount typically billed by similar providers within the same area for similar services. If you are in a PPO network and obtain services from a provider that is a member of your PPO network, UCR does not apply

Where can I get a PPO directory?

Your employer has a copy of the provider directories for the PPO’s associated with your plan. Updates are provided as needed. Most PPO networks have a web site that will allow you to locate providers based on location, specialty and other options. You can link to these PPO web sites from our web site using the PPO Links page. (Read our Privacy Policy.)

Must I submit a claim form to receive benefits?

Claim forms are not usually required in order to submit a claim to EGA. PPO providers submit your claims to us at the address on the back of your ID card. For some claims, additional information is required in order to correctly process the claim. Forms used for providing this information can be found on the Forms page of EGA’s web site.