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A closer look at your Explanation of Benefits.
What happens with Medicare claims?
Before going through the information on your Explanation of Benefits (EOB) statement, it helps to understand how Medicare claims are processed.
- Anytime you see a healthcare provider or receive a healthcare service, a claim is generated.
- When you see a provider who accepts Medicare assignment1, the claim first goes to Medicare for processing.
- After Medicare has determined how much it will pay and processed the claim, they send it to your Medicare Supplement Insurance company (WPS or EPIC) for processing.
- 1Visit to doctor or hospital
- 2Provider sends claim directly to Medicare
- 3Medicare processes claim
- 4Medicare sends claim to WPS/EPIC
- 5WPS/EPIC processes claim and creates EOB
Most providers accept Medicare assignment, but it’s always good to check with them before your visit.
If you see a provider that does not accept Medicare assignment, you may have to pay the full bill at the time of service. Also, providers that don’t accept Medicare assignment can charge you more than the Medicare-approved amount. Providers that “opt-out” of Medicare will not be paid by Medicare or your Medicare supplement policy, except for emergency services.
Preventive care services: Lab and x-ray testing.
Your Medicare Supplement Plan is designed to help pay for services that Medicare covers. If Medicare allows a service, your Medicare Supplement Plan usually does, too.
Wisconsin also requires Medicare Supplement Plans to cover certain preventive services each year. Because of this, your plan sometimes pays for tests when Medicare does not.
Lab and radiology tests may be processed differently. Medicare may deny a test if it’s billed as part of a routine visit—even when it was ordered for a specific medical reason. In many cases, Medicare would likely have covered the test if more detailed information had been included.
When it comes to lab and radiology tests, keep this in mind:
- If you receive a bill for a test you believe should have been covered, you can contact your provider and ask them to review the information sent to Medicare.
- Sometimes a claim can be resubmitted with more specific details.
- If you’re not sure about your tests, reach out to customer support: 888-253-2694
About Medicare claims processing
- Your Medicare Part A and B claims are submitted directly to Medicare by your providers (doctors, hospitals, labs, suppliers, etc.).
- Providers have up to a year to submit a claim to Medicare.
- Medicare takes approximately 30 days to process each claim.
- Medicare sends its own EOBs quarterly.
- Please note that your claims may not appear in date order on your Medicare EOB.
About WPS/EPIC claims processing
- After we receive your claim from Medicare, it takes us approximately 30 days to process it.
- After each claim has been processed, an electronic EOB will be available in your online Customer Portal.
- If we have processed any claims in the previous 30 days, an EOB will be mailed to you that includes all of the claims processed during that period.
- If you owe anything, your provider will send you a bill. If you receive a bill from a provider showing a balance due and are not sure if you owe, please call us at 888-253-2694.
How to read your Explanation of Benefits.
Your EOB has two main sections:
- Detailed Summary for Medical Claims
- Medicare Explanation of Benefits
This section is your Medicare Supplement Plan’s explanation of benefits. This is how WPS/EPIC handled the claim after receiving it from Medicare.
Helpful glossary:
Dates of Service: The start and end dates during which the listed procedure was performed.
Procedure/Revenue code: The code for the procedure or service billed by the provider. These codes are called Current Procedural Terminology (CPT®) codes. They provide a uniform nomenclature for coding medical procedures and services. To look up a CPT code, please visit one of these websites:
Billed Amount: The total cost of the procedure, as billed by the provider.
Provider: The entity that provided medical services on the date you were seen.
Provider Discount: Medicare has fixed amounts it has agreed to pay for services with healthcare professionals and facilities. This amount is the provider’s responsibility, and the amount is subtracted from the total billed amount.
Amount Allowed: This is the amount that WPS/EPIC will consider, based on your plan benefits.
Amount Not Covered: The portion of the total cost not covered by WPS/EPIC. This portion may be your responsibility.
Copay Amount: If you are on a copay plan, this is your copay amount. Copays for office visits can be no more than $20, and emergency room (ER) visits are $50.
Deductible Amount: You do not have a deductible with your Medicare Supplement Insurance Plan. This will always be $0.
Coinsurance Amount: If you are on a cost-share plan, this is the amount you owe for coinsurance.
Plan Paid: This is the amount that WPS/EPIC paid for the services you received.
What You Owe: This is the amount you may owe. This would include any copay, deductible, coinsurance, and any amount not covered. If an amount is owed, you will receive a bill directly from your provider.
Remark Code(s): Additional information regarding how your claim was processed. You can find out what the codes mean using the key in the Remark Code(s) definition box.
Remark Code(s) definition box: This contains the key to any Remark Codes used. Match the Remark Code to the key in this box to view the meaning of the specific comment.
Other Insurance Paid: This is the amount Medicare paid.
This section shows how Medicare handled the claim before sending to WPS/EPIC.
Helpful glossary:
Amount Allowed: This is the amount that Medicare allowed for the procedure or service.
Medicare Paid: This is the amount Medicare paid.
Deductible Amount: This is what Medicare applied to either the Part A or Part B deductible.
Medical Coinsurance: This is the amount left over that Medicare did not pay the provider.
Sequestration Amount: The Medicare sequestration cuts Medicare payments up to 2% annually. This is an automatic reduction of Medicare allowed amounts for certain services.
Patient Responsibility: This is the amount left over that Medicare did not pay. This is the amount that would have been sent to your Medicare Supplement Insurance company for processing. To see how WPS/EPIC processed this claim, please view the Detailed Summary for Medical Claims Only section of your EOB.
How to go paperless.
If you would like to receive your WPS/EPIC Explanations of Benefits (EOBs) electronically instead of in the mail, you can:
- Call customer support at 888-253-2694; OR
- Visit your customer portal at wpshealth.com.
To switch to paperless in your customer portal
- Log in to your account at wpshealth.com
- Click on Tools and Resources
- Click on Document Center
- Select the box that says Go Paperless, then click Save
The Go Paperless option in your Customer Portal Document Center.
1Providers may accept the Medicare-approved amount as payment, so you won’t be billed for more than the Medicare deductible and coinsurance. A WPS Medicare Supplement Insurance Plan will help cover the Medicare deductible and coinsurance. Visit medicare.gov to find a provider near you or check to see if your provider accepts the Medicare-approved amount.
Neither Wisconsin Physicians Service Insurance Corporation, nor The EPIC Life Insurance Company, nor their products, nor agents are connected with or endorsed by the United States government or the federal Medicare program. In AR, AZ, CO, FL, IA, KS, KY, MD, MO, ND, NE, NV, OK, OR, PA, SD, TN, TX, VA and WV, WPS Health Insurance Medicare Supplement Insurance Plans are underwritten by The EPIC Life Insurance Company, a wholly owned subsidiary of Wisconsin Physicians Service Insurance Corporation, the plan administrator. In IL, IN, MI, NT, OH, VT and WI, WPS Health Insurance is underwritten by Wisconsin Physicians Service Insurance Corporation. All policies have exclusions, limitations and reductions. Benefits vary by insurance plan and the premium will vary with the amount of benefits selected.
This information is not intended to constitute a solicitation to sell insurance. It is intended to educate our current customers only. This is not legal or medical advice. Please contact your legal counsel or physician/health care provider with any questions.