2021-2022 CLAIM REPORT ORIENTATION
This report displays the amount that each of your family members are responsible for in Plan Year 2021 and Plan Year 2022.
Date Range:
Plan Year 2021 includes service dates from May 1, 2021 to April 30, 2022
Plan Year 2022 includes service dates from May 1, 2022 to Dec 31, 2022
Deductible and OOP By Period:
Plan Year 2021 Deductible and Coinsurance Max =$1,000 OOP Max =$2,000
(Your 2021 Max Deductible and Coinsurance shown below may be less than $1,000 each due to CARRY OVER CREDITS from incurred service dates from May 1, 2021 to Dec 31, 2021 or Family Max Capping)
Plan Year 2022 Deductible and Coinsurance Max =$666 OOP Max =$1,332
Overpayments:
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
| Plan Year |
Name |
Max Deductible |
Max Coinsurance |
Deductible |
Coinsurance |
Plan Over (+) / Under (-) Payment |
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Detailed Break Down Per Claim
(In-Network Excluding QMG 100% Clinic)
| 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 |
Correct Carrier Owes |
HRA Budget |
BCBS Paid |
Plan Over (+) / Under (-) Payment |
HRA Owes |
HRA Payment |
Patient Owes Provider |
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Claim Summary for
(In-Network Excluding QMG 100% Clinic)
| Row |
Name |
Plan Year |
Total Billed |
Penalty |
Allowed Amount |
BCBS Paid |
Plan Over (+) / Under (-) Payment |
Amount Due Provider |
HRA Paid |
HRA Credit Payment |
Patient Owes Provider |
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Summary By Provider for
(In-Network Excluding QMG 100% Clinic)
| Provider |
Total Billed |
Penalty |
Allowed Amount |
BCBS Paid |
Plan Over (+) / Under (-) Payment |
Amount Due Provider |
HRA Paid |
HRA Credit Payment |
Patient Owes Provider |
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