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Anthem Health Insurance Frequently Asked Questions
Q. What is considered "Preventive Care" under the Bowdoin College Health Plan?
A. Preventive services are those submitted by your provider without a diagnosis. Examples of covered preventive services are: a general physical exam, routine lab work, routine immunizations, pap tests and mammograms.
Q. How is preventive care covered by the Bowdoin Health Plan?
A. Preventive care, including primary care office visits and "well woman" exams, are covered at 100% after a $15 office co-payment. It is very important for your doctor to submit preventive services without a diagnosis code so that they are paid correctly.
Q. What are "Medically Necessary" services?
A. "Medically necessary" services are those services submitted by your doctor with a diagnosis code. Examples of medically necessary services are: mole removal due to a diagnosed condition, physical manipulation due to a condition, bloodwork or a colonoscopy and sigmoidoscopy due to family history.
Q. How are medically necessary services covered under the plan?
A. After meeting the annual deductible of $300, medically necessary services (those submitted with a diagnosis) are covered at 90% when referred by your primary care physician, or at 70% when you self-refer.
Q. Do I have to meet the deductible when my primary care physician refers me for the service?
A. Yes. With the exception of preventive services, the annual deductible applies to benefits received with a referral as well as self-referred benefits. You do receive higher benefit levels when referred by your primary care physician, but you still have to meet the annual deductible. Examples of this are inpatient hospital services when referred by your primary care physician, and blood work associated with a diagnosis.
Q. Why have I been charged for other services associated with a specialist visit when I was referred by my primary care physician and paid the $25 office visit co-payment?
A. Your $25 co-payment has paid for the office visit consultation. Any procedures or manipulations performed in the office visit setting are not covered by the office visit co-payment. The charges for these ancillary services will first be applied to your annual deductible, and then paid at 90% if you received a referral, or paid at 70% if you self-referred to the specialist.
Q. My claims seem to be paid incorrectly. When I receive preventive care services, my claims are not paid at 100%. I pay the office co-payment, but then I receive bills from the provider. Why is this happening?
A. Many claim problems are the result of incorrect bills submitted by the providers. At the time you receive services, the doctor's office determines how your health insurance claims will be submitted for payment: they are either coded as preventive services or coded with a diagnosis code. Inaccuracy in coding by doctors' offices can cause claims to be processed incorrectly. Due to new privacy laws, Anthem will no longer call your doctor directly when a claims coding problem is suspected. In these cases, you must call your doctor directly to discuss the billing problem and have your claims re-submitted correctly. At the time you receive your health services, it is a good idea to discuss this concern with the doctor's office in order to be certain that your services will be billed correctly before you leave the office.
Q. Each time I get the Explanation of Benefits from Anthem after receiving services under the plan, I cannot read it. Why is this form so confusing?
A. Anthem has heard many comments about confusion with their Explanation of Benefits form, and they have agreed to change it. Although Anthem has agreed to simplify this Explanation of Benefits, it may be some time before this is accomplished. In the interim, Human Resources will be available to assist you to understand the Explanations of Benefits forms.
Q. Is there an easy way to tell how office visit charges will be paid?
A. Yes. The basic rule of thumb is that if it is a preventive service (and this includes most immunizations in conjunction with an office visit) it will be covered with an office visit co-payment of $15. Medically necessary services (those submitted with a diagnosis code) will be applied first to the annual deductible and then paid at either 90% (if referred) or 70% (if self-referred.) The enclosed chart may help you understand how each type of office visit is covered by the health plan.
We hope these responses to frequently asked questions assist you in understanding how your health and prescription drug benefits are covered under our new plan. If you experience difficulty in understanding either your benefits or on how claims are paid, please do not hesitate to call Anthem directly at 1-800-527-7706, or Human Resources at extension 3837. We will be glad to assist you.
| Type of Service | Referred Benefit Level | Examples |
|---|---|---|
| Primary Care Visits and Well Woman Exams PREVENTIVE CARE (Claims submitted with no diagnosis) |
100% after $15 office copayment | General Physical Routine Lab Work Routine Immunizations Pap Test Mammogram |
| Medically Necessary Procedures (Claims submitted with a diagnosis) | 90% after the deductible | Procedures performed in an office setting (i.e. mole/lesion removal, physical manipulations, colonoscopies and signmoidoscopies due to family history are paid in this category) |
| Specialist's Office Visit | 100% after the $25 office copayment | Consultations with the Specialist General Exam |
| Services Performed in a Specialist's office visit setting | 90% after the deductible | Any procedure or manipulation performed in the office visit setting |