Health Care Benefits: Claims Process
Submitting A Claim
Network Providers
If you receive services from a network provider, the provider will submit claim forms for you. Network providers file claims directly with Medical Mutual. Medical Mutual sends payment to the provider directly.
To ensure fast claim filing, you may wish to contact Medical Mutual to determine if the health care service is covered. Show your identification card to the provider and determine if the provider is in the Ohio Med network. Ask the provider to file the claim on your behalf. Remember, not all services are covered by this or any insurance plan. Ineligible expenses are your responsibility.
Non-Network Providers
You are responsible for filing claims for services received by non-network providers. You also will be responsible for filing claims for services for which you have paid directly.
Use a separate claim form for each person for whom you are filing a claim. Submit the original bills with the claim form and be sure to keep copies for your records. Add your identification number to each bill to speed processing.
Payments for services received at non-network or non-participating providers will be made to you. You must pay the provider. (However, for persons enrolled in the Traditional plan, Medical Mutual does pay the provider directly).
Explanation of Benefits
After the claim is paid, Medical Mutual will send you an Explanation of Benefits (EOB) which describes the benefits received, lists the payments to the provider and identifies expenses, if any, for which you are responsible. However, do not make payment to providers based on EOB information. Make payment based on a bill you receive from your provider.
Claims Appeal Process
Keep copies of all your bills, claims and correspondence. In some cases, a claim may be denied. You have the right to appeal that decision. If you wish to appeal a denied or reduced claim, there are some specific steps to take; however, check your health plan's description for details.
Department of Administrative Services Appeal
If all levels of appeal with your health plan have been exhausted and you disagree with the decision, you can file a complaint and/or request a benefit determination from the Department of Administration Services.
Submit a written request within 60 days of receiving your health plan's final written decision and supply the documentation from earlier appeals. Send your request and documentation to:
Benefit Appeal
Benefits Administration Services
30 East Broad St., 28th Floor
Columbus, OH 43215
A written decision will be given within 60 days after you submit your request. |
