How health insurance works

From your doctor’s office to your mailbox

Health insurance is a complex industry. There are a lot of steps that take place between the time you go to the doctor and when you pay your bill. Here is a simple outline of how Blue Cross of Idaho processes your claim from start to finish.

At your doctor’s office

After your appointment, the staff at the doctor’s office prepare a claim and sends it to Blue Cross of Idaho. The claim has information that helps us determine how a to pay a claim.

For example, a claim will include:

• Whether you saw an in-network or out-of-network provider
• If you are a current Blue Cross of Idaho member
• Procedure and diagnoses codes

The information on a claim helps us make sure that the same service is not paid twice and determine if the service needs to be approved with a prior authorization (PA).

It’s always best to check if a service needs a PA before you get it. You can call the Blue Cross of Idaho Customer Service Department at the number on the back of your member ID card to find out if you need a PA. If the service needs a PA, ask your provider to submit one before you set up an appointment for the service. Please know that in the case of an emergency, you do not need a PA.

At Blue Cross of Idaho

When we get a claim from a provider or healthcare facility, our staff reviews the claim. If the claim is missing information, we will send it to an examiner for a resolution. If the claim has all the right information, we approve the claim.

In your mailbox

Once the claim is approved, we create an Explanation of Benefits (EOB) and mail it to you. Your EOB is not a bill but is an outline of what you may owe once your provider bills you. We then pay the provider who you saw for your visit. Based on the service and what is covered under your plan, your provider may send you a bill for the amount that is left over.

Want more health insurance tips?

Health insurance can be confusing, but we have resources to help you find the information you need to understand your plan. Read our Blue Bulletin blog for information on topics like health insurance terms and other tips on understanding your benefits.

 

Posted: September 22, 2022