claims at a glance Oxford Claims Contact Information

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1 at a glance Medical Claim Submission Basics Usual, Customary & Reasonable Allowances Deductibles, Coinsurance & Out-of-Pocket Maximums Coordination of Benefits Health Reserve Account Claims Making Oxford MyPlan SM Work for You Oxford Claims Contact Information Do you need to download a claim form? www Log on to the Employer section of and click the Tools and Resources tab. Forms can be found under Practical Resources. Send all medical claim forms to: Send all Oxford MyPlan health reimbursement Oxford Health Plans account claims forms to: Attn: Claims Department Oxford Health Plans P.O. Box 7082 Attn: Oxford MyPlan SM Health Reserve Account Claims Dept. Bridgeport, CT P.O. Box 1021 Eatontown, NJ Do you have claims questions? Please call your Oxford Account Manager or Group Services at groupservices@oxfordhealth.com. Turnaround time is generally 24 hours www For Health Reserve Account claims questions, call Oxford MyPlan Special Services at For Health Savings Account claims questions, call Oxford at

2 Medical Claim Submission Basics When a Claim Form is Required There are cases when Oxford Members may be required to complete claim forms in order to receive reimbursement, such as: When Members have out-of-network coverage and/or obtain care on an out-of-network basis When Oxford is the secondary insurance carrier When Members receive laboratory services from a non-participating laboratory All covered charges for out-of-network medical treatment are subject to a deductible, coinsurance, and usual, customary and reasonable (UCR) limitations, as stated in your Certificate of Coverage. The most commonly used claim form is the HCFA-1500 Health Insurance Claim Form. An image of the HCFA-1500 Health Insurance Claim Form can be seen on the next page and can be downloaded from www In-network Claims When Members receive care on an in-network basis, there are usually no claim forms to complete. They simply show their Oxford ID card and pay any applicable cost shares (copayments). Members of Oxford s Freedom Plan Direct SM, Liberty Plan Direct SM, Oxford MyPlan SM, and Freedom Plan Value Option SM have to meet an in-network deductible or pay in-network coinsurance for certain in-network covered services. See your plan s Summary of Benefits for complete details regarding your coverage. Out-of-Network Claims The Member must complete an HCFA-1500 Health Insurance Claim Form, and send the claim form and the original provider invoice to: Oxford Health Plans Claims Department P.O. Box 7082 Bridgeport, CT Filing Deadlines: When Claims Must be Submitted Commercial Members have 180 days from the date of service to submit a claim to Oxford. Filing deadlines are based on the claim s date of service. They are not based on the date that the claim was mailed to or received by Oxford. Claims that are filled completely and correctly are usually processed within 10 to 15 business days. If you have any questions regarding a particular claim submission, please contact Oxford Group Services at

3 What to Complete on an HCFA-1500 Claim Form for Out-of-Network Claims Required Claims Information Box 1a. Insured s ID Number: Indicate Subscriber s Oxford ID Number Box 2. Patient s name Boxes 9a d. Other insured s name (Only complete section if patient has other insurance) Box 4 7. Insured s Name, Address and Telephone Number: Subscriber s contact information. Box 12. Signature authorizing release of medical information. Members who want to receive payment directly must sign Box 12 only and leave Box 13 blank. Box. 13. Signature authorizing assignment of benefits (if applicable). Members who want the payment of medical benefits to go directly to the undersigned physician or supplier of services must sign Box 13 in addition to Box 12 of the Claim Form. 41

4 What Should be Submitted with an HCFA-1500 Health Insurance Claim Form An original, itemized bill must also be submitted with the claim form and include the following: Patient s name; Provider s name; Provider s Federal Tax ID Number (FTIN); Oxford Member ID number; Date of service; Type of service; Description of service (CPT-4 code); Individual charges for each service; and Diagnosis codes (ICD-9 codes). The diagnosis codes must be included on the bill and claim form. The bill must appear on the provider s billing letterhead. Balance Due or Balance Forward statements will not be accepted. If a printable bill is not available, the bottom portion of the HCFA-1500 Health Insurance Claim Form. (boxes 14-33) must be completed and signed by the provider. Precertification Requirements for Out-of-Network Claims (This section does not apply to Oxford s in-network only plans.) For all products that have out-of-network benefits, most services that require precertification on an in-network basis also require precertification on an out-of-network basis. If a Member is receiving treatment from an out-of-network provider, it is the Member s responsibility to call Oxford s Customer Service Department at or the number on their Oxford ID card to precertify the procedures recommended by the outof-network provider. If medically necessary services are not available on an in-network basis, or an Oxford participating provider cannot be located within the area, then Oxford s Medical Management Department must precertify the services in order for coverage to be provided in-network, regardless of plan design. Members, regardless of plan design, who do not receive precertification will be obligated to cover all charges or will be subject to a reduction of coverage. Please refer to your Certificate of Coverage for more details. How to Check on Claims Status Members can check their claims: Online at by logging on to the Member section with their user name and password; www On Oxford Express (our voice interactive phone system)at ; or By calling our Customer Service Department at or at the number on the back of their ID card. 42

5 Usual, Customary and Reasonable Allowances For most out-of-network medical procedures, Oxford determines a usual, customary and reasonable (UCR) allowance based on Health Insurance Association of America (HIAA) or other industry data, Medicare fees, and other factors. For each billed procedure, the UCR allowance represents the maximum amount Oxford will reimburse or consider applying toward deductible and coinsurance payments. More information regarding the calculation of your group s UCR levels can be found in the Certificate of Coverage and Summary of Benefits. Please note that UCR amounts are reviewed periodically and can change without notice. Deductibles, Coinsurance and Out-of-Pocket Maximums Understanding Deductibles Whether your group offers plans with only out-of-network deductibles or both in- and out-of-network deductibles (Freedom Plan Direct SM, Liberty Plan Direct SM, Freedom Plan Value Option SM, Oxford MyPlan SM, Oxford Exclusive Plan SM, Oxford HSA Direct SM and Oxford HSA Exclusive SM ) your employee s coverage will be subject to coinsurance and an out-of-pocket maximum once the deductible is met. Members with single coverage: A single deductible is satisfied by incurring covered services up to the amount of the deductible. Members with two-person families: If the sum of the two single deductibles is less than the total family deductible amount, then each individual is only responsible for meeting his or her single deductible before coinsurance for out-of-network visits will apply to that individual. Members with family coverage: A family deductible is satisfied when a combination of applied individual deductibles equals the family deductible. Any combination of family members individual deductibles can satisfy the family deductible; however, no one person can contribute more than his or her single deductible amount. See example below. This example can be used to understand both in- and out-of-network deductibles. For example: In a family of four people, where the individual deductible is $200 and the family deductible is $500, the family deductible would be satisfied by the following situation in chronological order. Family Member #1 Incurs a bill for $300 The remaining $100 is subject to their coinsurance Meets $200 individual deductible Family Member #2 Incurs a bill for $400 + Meets $200 individual deductible The remaining $200 is subject to their coinsurance = $400 of the $500 family deductible is met Family Member #3 Incurs a bill for $200 + $100 meets the entire family deductible The remaining $100 is subject to their coinsurance = $500 Family deductible is met Family Member #4 Incurs a bill for $300. The entire claim will be subject to their coinsurance. 43

6 In-network Deductibles: In-network deductibles apply only to employers who offer Oxford s Freedom Plan Direct SM, Liberty Plan Direct SM, Freedom Plan Value Option SM, Oxford MyPlan SM, Oxford Exclusive Plan SM, Oxford HSA Direct SM and Oxford HSA Exclusive SM. These plans also have an out-of-network deductible (see section below). The in-network and out-of-network deductibles in these plans have to be satisfied independently before medical bills are subject to either the in- or out-of-network coinsurance. For example: Assume Joan has already satisfied her in-network deductible for this calendar year. Joan then incurs a bill from Dr. Bob, an in-network physician. Dr. Bob bills Oxford directly, and the bill is subject to Joan s in-network coinsurance. Now, Joan receives covered services from Dr. Smith, an out-of-network provider. Joan completes a HCFA-1500 Health Insurance Claim Form, and submits the claim form and the bill from Dr. Smith to Oxford. Since Joan has not satisfied her out-of-network deductible, the bill will be applied to her out-of-network deductible. Please note: Oxford Members are only responsible for their in-network deductible and coinsurance when receiving covered in-network services. Oxford participating physicians and other participating providers are not permitted to balance-bill the Member for any amount above the provider s contracted Oxford rate. Out-of-Network Deductibles: Please note that most billed amounts for covered services from an out-of-network provider are subject to a deductible, coinsurance, and UCR. The Member is responsible for any amount billed over the UCR. Prior Carrier Deductibles (New Groups Only) Oxford will provide credit for deductibles paid to previous carriers under the following conditions: Oxford will honor any previous deductibles paid to another health plan between January 1 and the effective date of your new Oxford policy; Deductible credit will only be given for the calendar year in which your Oxford policy first became effective and is only available to new Oxford groups; Deductibles will be credited in amounts equal to those applied to the previous health plan; and If Oxford s deductibles are higher than those of the previous plan, Oxford s deductible must be satisfied before benefits are paid. New hires to your company are not eligible for a deductible credit from their previous employer s medical plan. Credit for deductibles is available only to employees who were enrolled under the health plan that your group had before Oxford coverage began. 44

7 How to Receive Credit for Prior Carrier Deductibles Oxford will not obtain deductible information from your prior carrier. This is the responsibility of the Member. To obtain credit for deductibles paid to a prior carrier, Members should: Obtain Explanation of Benefits forms from the prior carrier showing the amounts of the deductibles applied; Complete a Prior Carrier Deductible Form (Members can download this form on or by calling Oxford Customer Service); and www Within 60 days of your policy s effective date, submit these forms to: Oxford Health Plans Attn: Deductible Credit Center P.O. Box 7081 Bridgeport, CT Understanding Coinsurance & Out-of-Pocket Maximums The basic principles for coinsurance and out-of-pocket maximums can be applied to plans that have in- and/or out-of-network benefits. Members enrolled in plans that have both in- and out-of-network deductibles and coinsurance need to satisfy the in- and out-of-network deductibles, coinsurance, and out-of-pocket maximums independently. Once a Member s deductible is met, claims will be reimbursed subject to coinsurance up to the out-of-pocket maximum specified in the Summary of Benefits. The deductible and coinsurance percentages applied to the Member's claims are not based on billed charges. They are based on either the in-network provider s Oxford contracted rate (in-network charges only) or on the charges deemed usual, customary and reasonable (UCR) by Oxford (out-of-network charges only). Only the Oxford contracted rate or UCR amount is applied to the Member s deductible. Once the Member s deductible has been met, then the coinsurance percentage of the contracted rate or UCR is applied to the out-of-pocket maximum. Please note (out-of-network only): The Member is always responsible for paying any charges above the UCR amount for out-of-network providers. See Usual, Customar and Reasonable Allowances. A Member s out-of-pocket maximum represents the amount of money in deductible and coinsurance that an individual and/or family must pay before claims are reimbursed by Oxford at 100 percent of the contracted rate (in-network charges only) or UCR allowances (out-of-network charges only). Members should refer to the Summary of Benefits for their coinsurance percentage and out-of-pocket maximum. 45

8 The information in the following two examples are based on this Member profile. Single Deductible: $200 Single Out-of-Pocket Maximum: $1,200 Family Deductible: $500 Family Out-of-Pocket Maximum: $3,000 Coinsurance: 80%/20% Deductible + Coinsurance = Out-of-Pocket Maximum Example #1 illustrates how the following instance can be applied during an in- or out-of-network situation. Teri receives a bill for $100 from Dr. Smith. The contracted rate (in-network) or UCR (out-of-network) for that procedure is $75. Assuming that Teri has met her applicable single deductible of $200, then Oxford is responsible for 80% of the contracted rate or UCR (80% x $75 = $60). Teri is responsible for 20% of the contracted rate or UCR (20% x $75 = $15). For out-of-network plans only: In-network Out-of-Network Billed Amount $ 1100 $ 1100 Contracted Rate/UCR $ 1175 $ 1175 Oxford pays 80% coinsurance (80% x $75) $ 1160 $ % Coinsurance amount (20% x $75) $ 1115 $ 1115 Amount above UCR (out-of-network only) N/A ($100 $75) + $ 25 Total amount Teri owes Dr. Smith $ 1115 $ 1140 Single out-of-pocket maximum $ 1200 $ 1200 Accumulated deductible + coinsurance ($200 + $15) $ 1215 $ 1215 Remaining out-of-pocket maximum $ 1985 $ 1985 Teri is also responsible for the difference between the billed amount and the UCR ($ = $25). 46

9 Example #2 illustrates how the following instance can be applied during an in- or out-of-network situation. Teri incurs a second bill from Dr. Smith for $8,000. The contracted rate or UCR is equal to the billed amount. Oxford pays 80% of the contracted rate or UCR (80% x $8,000= $6,400). Again, Teri is responsible for 20% of the contracted rate or UCR. For out-of-network plans only: Teri is also responsible for the difference between the billed amount and the UCR ($8,000 $8,000 = $0). Since the amount owed to Dr. Smith exceeds Teri s out-of-pocket maximum, she is responsible only for the remaining $985 of her out-of-pocket maximum, and Oxford is responsible for the $615 difference. Now that Teri has met her out-of-pocket maximum (deductible + coinsurance), Oxford is responsible, from this point forward, for 100% of the contracted rate for all in-network procedures, or UCR for all out-of-network procedures or visits incurred for that calendar year. Teri is still responsible for amounts above the UCR. In-network Out-of-Network Remaining out-of-pocket maximum $ 1,985 $ 1,985 Second billed Amount from Dr. Smith $ 8,000 $ 8,000 Contracted rate/ucr $ 8,000 $ 8,000 Oxford pays 80% coinsurance (80% x $8,000) $ 6,400 $ 6,400 Teri pays 20% coinsurance (20% x $8000) $ 1,600 $ 1,600 Amount above UCR (out-of-network only) N/A ($8000 $8000) + $ 0 Total amount Teri owes Dr. Smith $ 1,600 $ 1,600 Remaining out-of-pocket maximum Teri needs to meet $ 1,985 $ 1,985 Teri s 20% coinsurance amount - $ 1,600 - $ 1,600 Remaining out-of-pocket maximum $ 0 $ 0 (Teri has now met her out-of-pocket maximum) Teri has met her out-of-pocket maximum, and Oxford pays the remaining $615 to Dr. Smith ($1600 $985) $ 1,615 $ 1,615 Teri pays Dr. Smith $ 1,985 $ 1,985 Important Points to Remember: The Member s deductible and coinsurance are reset to zero at the beginning of every calendar year for most Oxford groups. Members with out-of-network coverage will remain responsible for the coinsurance level of the UCR until his or her out-of-pocket maximum or the family out-of-pocket maximum for that calendar year is met. Members with out-of-network coverage are always responsible for any difference between the UCR and billed amount, regardless of whether the out-of-pocket maximum has been met. 47

10 Coordination of Benefits (COB) If a spouse or dependent becomes an Oxford Member while also covered by another health insurer, one insurer will be considered primary, while the other will be considered secondary. All claims must first be evaluated by the primary health insurance carrier before they are submitted to the secondary carrier. It is essential for Oxford to know about any duplicate coverage information, even if it is for only one family member. COB questionnaires are mailed to Members who fail to adequately complete the other carrier question on the Member Enrollment Form (See Enrollment of Eligible Employees and Their Dependents). Please see your Certificate of Coverage for specific details regarding Oxford s coordination of benefits policies with other insurers. Oxford as the Secondary Health Insurance Carrier When Oxford is the secondary carrier for a Member, all claims for healthcare services must first be evaluated by the primary insurer before Oxford benefits will be considered. This includes all claims that are covered by: Another health insurance company Auto insurance Workers compensation insurance For example, a Member s spouse is insured by both Oxford and XYZ Health. XYZ Health is the primary carrier, and Oxford is the secondary carrier. The Member s spouse receives treatment from a dermatologist. First, the claim must be processed by XYZ Health. Then, an Explanation of Benefits from XYZ Health needs to be submitted to Oxford, along with an itemized bill, for Oxford to determine payment. Determining the Secondary Health Insurance Carrier If a person is covered by more than one plan, Oxford makes a determination of which plan is primary based on criteria that may include the insured s status as either subscriber, spouse/partner, or dependents, their marital status and the presence of a divorce /court decree and date of birth. In addition, if the other carrier is Medicare, criteria may include their working status as either working, retired or disabled and the size of the group. Please refer to your Certificate of Coverage for more information. 48

11 Submitting a Claim When Oxford is the Secondary Health Insurance Carrier In order for Oxford to consider a claim as the secondary insurer, Members should attach an Explanation of Benefits (EOB) from the primary insurer, along with a completed HCFA-1500 Health Insurance Claim Form and original provider invoice. For instructions on how to complete a claim form, see section: What to Complete on an HCFA Health Insurance Claim Form. Health Reserve Account Claims The following section only applies to employers who have Oxford MyPlan SM. Important Notes: The Oxford MyPlan SM Health Reserve Account is based on a health reimbursement arrangement (HRA), which is subject to the requirements of the Internal Revenue Code. Groups may want to consult a tax advisor regarding these accounts. Neither Oxford Health Insurance, Inc., Oxford Benefit Management SM (OBM) or any other affiliate of Oxford Health Plans, LLC shall act as a fiduciary for the employer group. Information in this document is subject to change without notice. Oxford MyPlan SM Coverage Oxford MyPlan covers in-network preventive care at 100%, with no deductible. Oxford MyPlan has a deductible for both in- and out-of-network services. Generally, this deductible applies to all covered services, unless your plan includes an office visit copayment. If your plan has in-network deductibles for most services, Members will need to pay attention to what type of care is needed and how much it will cost. Members are in charge of where and when they access care and when they incur out-of-pocket expenses. Oxford MyPlan Health Reserve Account The Health Reserve Account helps Members pay for covered out-of-pocket expenses that fall under the deductible or coinsurance provisions of their plan. Understanding what healthcare really costs is a key component of the Oxford MyPlan, and, after Members receive care, they will receive a detailed EOB report that shows exactly how much their care costs, and calculates how much is covered under the deductible. Members will use the EOB to apply for reimbursement from their Health Reserve Account. Since they will be drawing on either their Health Reserve Account or personal funds until they meet the deductible limit, they will want to control their spending carefully. After exhausting the Health Reserve Account funds, Members are responsible for the remaining deductible. The employer is solely responsible for funding the Health Reserve Account. Oxford MyPlan in Action To help you better understand how the Health Reserve Account works, we have created two Member profiles and outlined typical medical expenses. Member experiences and cost shares may be different from the examples and will be based on their specific choices and plan design. These figures are for illustrative purposes only. 49

12 Example #1 Jane Smith is single and living in Tarrytown. Oxford MyPlan Deductible (single): $1,000 Health Reserve Account: $500 Jane sees an in-network allergist. The allergist sends claim to Oxford as he/she normally would. Oxford adjudicates claim, approving the contracted rate of $135. Oxford sends an EOB to both Jane and her allergist stating that $135 has been applied to Jane s deductible. Jane has two choices for using her Health Reserve Account: 1. She may assign payment from her Health Reserve Account directly to her allergist. By sending her EOB to Oxford, she will generate a $135 payment from her Health Reserve Account to her allergist. 2. She can pay her allergist the $135 directly, and submit an Oxford My Plan Health Reserve Account Claim Form to Oxford, along with her EOB and a receipt from the allergist. This will generate a $135 payment from the Health Reserve Account directly to Jane. Oxford will debit the Health Reserve Account, leaving a balance of $365 for future expenses. Jane has participated in the actual healthcare cost transaction, but, because of the Health Reserve Account, she has not incurred any out-of-pocket expense. Example #2 Eddie Lopez is married with two kids and lives in Queens. Oxford MyPlan Deductible (family): $2,000 Health Reserve Account: $1,000 Eddie s son John cuts his finger, and it looks like he ll need stitches. Eddie doesn t know if he should go to the urgent care center or the hospital emergency room (ER) just around the corner. Because his Oxford MyPlan has an in-network deductible, he knows his Health Reserve Account will cover his costs, up to the first $1,000. Eddie realizes that John s in no immediate danger. Because he knows that visits to urgent care centers typically cost less than visits to the ER, Eddie decides to take his son to the urgent care center. Oxford adjudicates the claim from the urgent care center at $145, sends an EOB to both parties, and applies $145 to Eddie s deductible. Eddie may choose to assign the payment directly to the urgent care center, or make a payment himself and submit the receipt with EOB and claim form to Oxford for reimbursement. Eddie s Oxford MyPlan Health Reserve Account balance is adjusted to $855. Eddie has taken a first step at understanding how healthcare decisions can impact his Health Reserve Account. Eddie has become a more engaged healthcare consumer. And by choosing the more efficient care choice, he has used his Health Reserve Account dollars wisely and hasn t incurred out-of-pocket costs. 50

13 Making Oxford MyPlan SM Work for You How Oxford MyPlan Medical Claims Work Generally, Members will not pay the provider at the time of service (certain plans include copayment provisions for physician office visits). After a Member s office visit, the doctor or other provider will submit a claim to Oxford. Here s what happens next: Oxford adjudicates the claim and determines which amounts should be applied to the deductible, coinsurance, or other benefits. Oxford sends an Explanation of Benefits (EOB) to the provider and to the Member explaining how much the Member owes the provider, if applicable. The in-network provider will then bill the Member for any amounts due under their deductible and coinsurance. Out-of-network claims are different. The out-of-network claim will be adjudicated by Oxford, and the approved charges may be reduced based on the Member s usual, customary and reasonable (UCR) level of reimbursement. The Member may still owe the provider charges beyond the deductible and coinsurance charges outlined on their EOB. Charges above the UCR are not eligible for reimbursement from the Member s Health Reserve Account. How Members Use Oxford MyPlan Health Reserve Account to Pay Claims After receiving care, Members will receive an EOB from Oxford that illustrates which charges may be applied to their deductible or coinsurance. The deductible amounts are eligible for reimbursement from their Health Reserve Account. Here s what Members can do: Option 1: Automatic Payment to the Provider The Member submits the EOB and an Oxford MyPlan SM Health Reserve Account Claim Form to the Oxford MyPlan address listed on the form. A sample of the form can be seen on the following page. He/she selects the Assignation of Payment box on the form to indicate that he/she wants the payment to go directly to his/her provider. All forms are available at www Oxford will send payment for all eligible expenses (up to the remaining Health Reserve Account balance) directly to the provider. The Member will receive a statement confirming that this payment has been made. Option 2: Pay the Provider and get Reimbursed After receiving an EOB from Oxford, the provider will send the Member a bill for the approved charges, which should match the amount indicated on the EOB. The Member should pay the provider the approved amount. The Member should keep a copy of the bill and get a receipt from the provider. The Member should submit the EOB, the receipt, and an Oxford MyPlan Health Reserve Account Claim Form to the Oxford MyPlan address as indicated on the form. Oxford will send payment for all eligible expenses (up to the remaining Health Reserve Account balance) directly to the Member. 51

14 Oxford MyPlan Health Reserve Account Claim Form Important things to remember: Members need to indicate in the Assignation of Payment box to whom the payment should be sent. Members need to submit a copy of their EOB and a receipt (if they are asking to be reimbursed) with the claim form. 52

15 What Expenses are Eligible for Reimbursement? The Oxford MyPlan SM Health Reserve Account may be used to reimburse all covered charges applied to the deductible or applicable coinsurance costs. Check your Summary of Benefits for information specific to your plan. What Expenses are Not Eligible for Reimbursement? The Oxford MyPlan Health Reserve Account does not reimburse money spent on the following services: Pharmacy copayments or deductibles Out-of-network charges in excess of the allowed amount Denied claims Dental, vision, or other services not covered by the insured health plan Office visit copayments (where applicable) How Pharmacy Claims Work Most Oxford MyPlan plan designs include pharmacy coverage. That benefit is independent from the medical benefits, and may include a separate deductible. Pharmacy charges are not eligible for reimbursement under the medical deductible. Oxford s pharmacy plans provide many incentives to use cost-effective medications, and deductibles are generally more moderate than medical deductibles. Consult your Certificate of Coverage for full pharmacy benefit details. How Members Get Information on Deductibles or Oxford MyPlan Health Reserve Account Balances The Oxford MyPlan Special Services team is available during business hours to give Members information regarding balance information. The toll-free phone number for Oxford MyPlan Special Services can be found on the Member ID card, or by calling