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Claims

In-Network Providers

If you receive services from a network provider, the provider will submit claims for you. Network providers file claims directly with your third-party administrator (TPA) and then the third-party administrator sends payments directly to the providers.

To ensure fast claim filing, you may wish to contact your third-party administrator to determine if the medical service is covered. Show your identification card to the provider and determine if the provider is in the Ohio Med PPO network. Remember, not all services are covered by the Ohio Med PPO plan. Ineligible expenses are your responsibility.

Non-Network Providers

You may be responsible for filing claims for services received by non-network providers. You also may 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 eligible services received at non-network or non-participating providers will be made to you by check. You must then pay the provider.

Explanation of Benefits

After the claim is paid, your third-party administrator 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 the explanation of benefits information. Make payment based on a bill you receive from your provider.

Claims Appeals

Keep copies of all your bills, claims and correspondence. In some cases, a claim may be denied by your third-party administrator. 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. Refer to your third-party administrator plan description for details on appealing claims.

Coordination of Benefits

You and your family members may have coverage under more than one medical plan. The medical plans include a coordination of benefits provision to eliminate duplication of payment for services. However, there is no coordination of benefits for prescription medications. Refer to your plan description for more details on the coordination of benefits.