CLAIM REPORT ORIENTATION
Allowed = amount due provider
This report displays the amount that each of your family members are responsible for in Plan Year 2023.
Date Range:
Plan Year 2023 includes service dates from January 1, 2023 to Dec 31, 2023
Deductible and OOP By Period:
The report may display Overpayment amounts in either plan year. Overpayments are sometimes created this year due to the extra layers of protection that the Plan Underwriter had to deploy in order to accommodate a deductible carryover credit and a short year deductible from May 1, 2022 to Dec 31, 2022. Any unintended Plan Overpayments will be used to offset future plan liabilities or settled at the end of the year.
Need Help?:
Contact the Help Desk by emailing
healthplanhelpdesk@coalitionexchange.org
Select Plan Year:
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Name |
Relationship |
Allowed Amount Subject To Deductible/Coinsurance |
Amount You Should Owe Under The Deductible In Force For Selected Year
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Actual Amount Owed Providers Due To BCBS Payments |
res-patientowes |
tpahraowes |
tpahraowes-res-patientowes |
Are You Due Additional Funds? |
Amount Due or Overpaid |
| Plan year |
Name |
Total BCBS Billed |
Total BCBS Allowed |
Total BCBS Paid |
Total Due Provider |
Total BPA Owes |
Total Employee Real Responsibility |
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Claims Subject to Deductible and Coinsurance (Excludes QMG Clinic and Preventative Claims) for
| Processed Date |
Date of Service |
Name |
Claim Number |
Provider |
Pay Your Provider |
Total Billed |
Penalty |
Allowed Amount |
Amount Due Provider |
Plan Year |
Correct Deductible |
Correct Coinsurance |
Correct Patient Owes |
Correct Carrier Owes |
BCBS Paid |
HRA Plan
Over (+) / Under (-)
Credit Attribution |
HRA Owes |
HRA Responsibility |
Corrected Pay your provider |
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| Processed Date |
Date of Service |
Name |
Claim Number |
Provider |
Pay Your Provider |
Total Billed |
Penalty |
Allowed Amount |
Amount Due Provider |
Plan Year |
Correct Deductible |
Correct Coinsurance |
Correct Patient Owes |
Correct Carrier Owes |
BCBS Paid |
HRA Plan
Over (+) / Under (-)
Credit Attribution |
HRA Owes |
HRA Responsibility |
Corrected Pay your provider |
Detailed Break Down Of QMG 100% Free Employee Clinic Claims for
| Processed Date |
Date of Service |
Name |
Claim Number |
Provider |
Total Billed |
Penalty |
Allowed Amount |
Amount Due Provider |
Plan Year |
Correct Deductible |
Correct Coinsurance |
Correct Patient Owes |
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Detailed Break Down Of Preventative Claims for
| Processed Date |
Date of Service |
Name |
Claim Number |
Provider |
Total Billed |
Penalty |
Allowed Amount |
Amount Due Provider |
Plan Year |
Correct Deductible |
Correct Coinsurance |
Correct Patient Owes |
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| Date Of Service |
Place Of Service |
Billed Amount |
Allowed Amount |
Carrier Paid |
Your Responsibility |
Primary Diagnosis |
Procedure Description |
Procedure Code |
Deductible |
Coinsurance |
Copay |
Penalty |
Medication Name |
Medication QTY |
Medication Supply |
LineId |
Department |
Service Provider |
Match Test Dept |
Match Test Provider |
Match Test CPT |
100 Percent Marker |
CPT CSV grouped |
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