Lifecycle of a Claim

1STEP Doctor Visit

After you go to the doctor, his or her office will file a claim for the service(s) provided. Each service has a procedure and diagnosis code. The procedure code tells us what was done during the visit Have you ever wondered what happens to your and the diagnosis code tells us why. It’s important to ask your doctor about the procedures being performed and how they claim between the time you go to the doctor and the time you STEP are being coded. This can help you avoid surprises when your Explanation of Benefits (EOB) arrives.

receive your bill? Each 2claim has its own lifecycle, containing STEP several steps to confirm accuracy. Claim Filed 3 Claim Your claim is filed with Network Health either Processed electronically or through the mail. Claims received electronically automatically load into our The Network Health claims processing system is set system. Paper claims are dated when they are up to coincide with your benefits, and your claim is received and converted into electronic files either processed automatically or reviewed by a STEP or manually entered into our claims processing system. claims analyst. This process ensures accuracy of the claim.

4STEP

5Verified Reviewed

When your claim is processed, we ensure your insurance coverage was effective on the date you received the service. Our processing system automatically verifies the service is covered and the doctor you saw is in-network. Your claim and benefits are reviewed. If your doctor is in the Network Health provider network, we pass discounts on to you, meaning you owe less than if you saw an out-of-network provider. This review also determines if you owe out-of-pocket costs, like a deductible. Then, our system applies your deductible to your claim, if applicable, and notifies your doctor what you owe.

STEP Explanation6 of Benefits (EOB)

We pay the eligible amount—less any out-of-pocket costs, such as coinsurance or copayments—directly to the provider. You receive the EOB, explaining how your claim was processed. The EOB is not a bill. Rather, it is a breakdown of how your claim was processed.

STEP 7

Billing

Once Network Health pays your doctor, it’s posted to your record, which you can view from the member portal at login.networkhealth.com. Your doctor’s office sends you a statement showing the remaining amount you owe, if anything. It’s important to compare the provider bill to your EOB to ensure you are being billed the correct amount.