What are the most common things to understand about a claim?

The most common things to look for and understand about a claim are the dates and costs listed for each service, test, lab work and procedure performed by each provider.

The fields you should always check are:

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  1. [DATE AND TYPE OF SERVICE] Shows the doctor/provider’s name; the month, day, and year the service was provided; and brief description of the service.
  2. [SUBMITTED CHARGES] The amount the doctor/provider billed Aetna for the service.
  3. [NEGOTIATED OR ALLOWED] Negotiated is the amount the doctor/provider has accepted as their charge for the service provided since they are part of Aetna’s network of providers. Allowed is the maximum amount allowed for a service/procedure if the provider is not participating in an Aetna network.
  4. [Patient Responsibility] Shows any dollar amounts for which you may be responsible for paying.

It is important to understand what’s covered by the plan. Remember, the cost of routine preventive care services (such as routine exams, well-child care, cancer screenings and immunizations) is typically covered at 100%.

The claim statement also includes a chart showing your Plan Summary (shown below):

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  1. The annual limits of your deductible and coinsurance. You can also see your year-to-date expenses and how much remains to be met before the plan begins to pay benefits.
  2. Information about payments made directly from your HealthFund.
  3. Summary of payments made to providers.

If you have questions about your claim information or if you think something is missing or incorrect, you can:

Call the LM HealthWorks Plan at 1-877-458-4975 and a customer service representative will answer questions about how a claim was processed and paid.

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