Claims Administration

Question: What information is needed from me when I call to ask for information regarding my Insurance Plan?

Answer: In order to protect patient privacy, a unique identifying number has been placed in the lower right hand corner of the covered member's insurance I.D card. We will require this number before any information will be released. If you are calling with questions about a specific claim, it will be helpful if you have the Explanation of Benefits on hand to discuss your claim questions with the Customer Service Representative.


Question: My Explanation of Benefits shows me a part of the charges, for a recent visit to my physician, were applied to a deductible and to a co-insurance. What is a deductible and co-insurance?

Answer:

Question: I received a document in the mail titled "Explanation of Benefits". A dollar amount for my co-payment is showing in the "patient responsibility" column, but I paid my co-payment at the Physicians office at the time of service. What do I owe?

Answer: "Explanation of Benefits" is sent from St. John's Claims Administration to the patient to show how a claim was processed. This is not a bill. Any payments made by you for this date of service is not reflected on the Explanation of Benefits. The Physician's billing office also receives a copy of the Explanation of Benefits. If there is a balance due you will be receiving a statement from the Physician's billing office.


Question: I received an Explanation of Benefits from St. John's Claims Administration for my visit to the Physicians office and there is an ineligible amount listed. Why is this amount not covered?

Answer: There is a "Remarks" section on your Explanation of Benefits that will explain why these charges were rejected according to your benefit plan guidelines. If you have additional questions about these remarks, please call the number for St. John's Claims Administration Customer Service. This phone number is located on the back of your Insurance ID card.


Question: I received a statement from my Physician's office that says nothing has been received from my insurance. Why haven't you processed my claim?

Answer: Either the claim was never received by St. John's Claims Administration or the claim was received, but additional information was requested from you or your physician. If claim was not received you need to verify with your Physician's Office that they have the current mailing address for St. John's Claims Administration. It is always a good idea to present your most current insurance ID card each time you visit your Physician's office to insure they have the correct address for claim filing. This requested information must be received in order for your claim to be processed. If you have not received this request for information, or a copy of the letter that was sent to your physician for this request, please call our customer service department and they will by happy to send you a copy of the original request.

Contracting Question and Answers

Question: How can I find out if a particular provider is in network for my insurance plan?

Answer: You should have received a provider directory from either your employer or insurance carrier. Due to the fact that changes are constantly occurring, the safest way to ensure the status of a provider is to contact the customer service number on your ID card. If you think a provider should be in network but your insurance company is not showing them listed, contact the provider's office and let them know.


Question: Am I able to access a listing online of current providers for my company?

Answer: Yes, this web site contains provider listings for each of our direct contracts along with links to additional web sites for our network contracts.

Question: Who do I call if I have benefit questions or if my claim has been processed incorrectly?

Answer:  We do not quote benefits in this office. There should be a customer service number listed on your ID card that you can call for assistance. If you feel your claim has been processed incorrectly, you should contact either your provider's office, the phone number on your statement, or your insurance company.


Question: How do I request that a physician be added to the St. John's Health System Network?

Answer: You can either submit a request through your insurance company or directly to St. John's Health Plans. Please remember that not all of the employer groups or managed care companies that contract with St. John's has opted to include every physician, hospital or provider that St. John's has in its network.