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									Claims

 At a glance
      Medical Claim Submission Basics                      Coordination of Benefits
      Usual, Customary and                                 Health Reserve Account Claims
      Reasonable Allowances
                                                           Making Oxford MyPlansm Work for You
      Deductibles, Coinsurance and
      Out-of-Pocket Maximums




Claims Contact Information
Do you need to download a claim form?

        • Log on to the Employer section of www.oxfordhealth.com and click the “Tools and Resources” tab.
         Forms can be found under Practical Resources.     www


 Send all medical claim forms to:             Send all Oxford MyPlan health reimbursement
   Oxford                                     account claim forms to:
   Attn: Claims Department                    Oxford
   P.O. Box 7082                              Attn: Oxford MyPlan Claims Dept.
                                                                     sm



   Bridgeport, CT 06601-7082                  P.O. Box 1021
                                              Eatontown, NJ 07724

Do you have claims questions?
• Please call your Account Manager or Client Services at 1-888-654-0065.
• E-mail: groupservices@oxfordhealth.com. The response time is generally within 24 hours.   www


• For Health Reserve Account claims questions, call Oxford MyPlan Special Services at 1-800-588-8621.
• For Health Savings Account claims questions, call us at 1-800-201-6953.




                                                      39
Claims
Medical Claim Submission Basics
When a Claim Form is Required
There are cases when members may be required to complete claim forms in order to receive reimbursement, such as:

• When members have out-of-network coverage and/or obtain care on an out-of-network basis
• When we are the secondary insurance carrier
• When members receive laboratory services from a non-participating laboratory
All covered charges for out-of-network medical treatment are subject to a deductible, coinsurance, and usual,
customary and reasonable (UCR) limitations, as stated in your Certificate of Coverage.

The most commonly used claim form is the HCFA-1500 Health Insurance Claim Form. An image of the HCFA-1500
Health Insurance Claim Form can be seen on the next page and can be downloaded from www.oxfordhealth.com. www


In-network Claims
When members receive care on an in-network basis, there are usually no claim forms to complete. They simply
show their ID card and pay any applicable cost shares (copayments).

Members of Freedom Plan® DirectSM, Liberty PlanSM Direct, Oxford MyPlanSM, and Freedom Plan® Value OptionSM
have to meet an in-network deductible or pay in-network coinsurance for certain in-network covered
services. See your plan’s Summary of Benefits for complete details regarding coverage.


Out-of-Network Claims
The member must complete an HCFA-1500 Health Insurance Claim Form, and send the claim form and the
original provider invoice to:

    Oxford
    Claims Department
    P.O. Box 7082
    Bridgeport, CT 06601-7082


Filing Deadlines: When Claims Must be Submitted
• Commercial members have 180 days from the date of service to submit a claim to us.

• Filing deadlines are based on the claim’s date of service. They are not based on the date that the claim was
 mailed to or received by us.

• Claims that are filled in completely and correctly are usually processed within 10 to 15 business days.
If you have any questions regarding a particular claim submission, please call Client Services at 1-888-654-0065.




                                                        40
Claims
What to Complete on an HCFA-1500 Claim Form for Out-of-Network Claims
Required Claims Information




                                                           Box 1a. Insured’s ID number
                                                           (indicate subscriber’s Oxford
                                                           ID number)




Box 2. Patient’s name

                                                           Boxes 4 – 7. Insured’s
                                                           name, address and telephone
 Boxes 9a – d.                                             number (subscriber’s contact
Other insured’s                                            information)
name (only
complete section
if patient has
other insurance)




                                                      Box 13. Signature authorizing
                                                      assignment of benefits (if
Box 12. Signature authorizing
                                                      applicable). Members who want
release of medical information.
                                                      the payment of medical benefits
Members who want to receive
                                                      to go directly to the undersigned
payment directly must sign Box
                                                      physician or supplier of services
12 only and leave Box 13 blank.
                                                      must sign Box 13 in addition to
                                                      Box 12 of the Claim Form.




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Claims
What Should be Submitted with an HCFA-1500 Health Insurance Claim Form
An original, itemized bill must also be submitted with the claim form and include the following:

• Patient’s name;
• Provider’s name;
• Provider’s Federal Tax ID number (FTIN);
• Member ID number;
• Date of service;
• Type of service;
• Description of service (CPT-4 code);
• Individual charges for each service; and
• Diagnosis codes (ICD-9 codes). The diagnosis codes must be included on the bill and claim form.
The bill must appear on the provider’s billing letterhead. Balance Due or Balance Forward
statements will not be accepted.

If a printable bill is not available, the bottom portion of the HCFA-1500 Claim Form, (boxes 14-33) must be
completed and signed by the provider.


Precertification Requirements for Out-of-Network Claims
(This section does not apply to our in-network only plans.)

• For all products that have out-of-network benefits, most services that require precertification on an in-network
 basis also require precertification on an out-of-network basis. If a member is receiving treatment from an
 out-of-network provider, it is the member’s responsibility to call Customer Service at 1-800-444-6222 or the
 number on their ID card to precertify the procedures recommended by the out-of-network provider.

• If medically necessary services are not available on an in-network basis, or a participating provider cannot be
 located within the area, then our Medical Management Department must precertify the services in order for
 coverage to be provided in-network, regardless of plan design.

• Members, regardless of plan design, who do not receive precertification will be obligated to cover all charges or
 will be subject to a reduction of coverage.

• Please refer to your Certificate of Coverage for more details.

How to Check on a Claim’s Status
Members can check their claims:

• Online at www.oxfordhealth.com by logging on to the member section with their user name and password;        www


• On Oxford Express® (our voice interactive phone system) at 1-800-444-6222; or
• By calling our Customer Service Department at 1-800-444-6222 or at the number on the back of their ID card.




                                                         42
Claims
Usual, Customary and Reasonable Allowances
For most out-of-network medical procedures, we determine a usual, customary and reasonable (UCR) allowance
based on Health Insurance Association of America (HIAA) or other industry data, Medicare fees, and other factors.

For each billed procedure, the UCR allowance represents the maximum amount we will reimburse or consider
applying toward deductible and coinsurance payments. More information regarding the calculation of your group’s
UCR levels can be found in the Certificate of Coverage and Summary of Benefits. Please note that UCR amounts
are reviewed periodically and can change without notice.


Deductibles, Coinsurance and Out-of-Pocket Maximums
Understanding Deductibles
• Whether your group offers plans with only out-of-network deductibles or both in- and out-of-network deductibles
 (Freedom Plan® DirectSM, Liberty PlanSM Direct, Freedom Plan® Value OptionSM, Oxford MyPlanSM, Oxford Exclusive
 PlanSM, Oxford® HSA DirectSM and Oxford® HSA ExclusiveSM) your employee’s coverage will be subject to coinsur-
 ance and an out-of-pocket maximum once the deductible is met.

• Members with single coverage: A single deductible is satisfied by incurring covered services up to the amount of
 the deductible.

• Members with two-person families: If the sum of the two single deductibles is less than the total family deductible
 amount, then each individual is only responsible for meeting his or her single deductible before coinsurance for
 out-of-network visits will apply to that individual.

• Members with family coverage: A family deductible is satisfied when a combination of applied individual deductibles
 equals the family deductible. Any combination of family members’ individual deductibles can satisfy the family deductible;
 however, no one person can contribute more than his or her single deductible amount. See example below.




  This example can be used to understand both in- and out-of-network deductibles: in a family of four people,
  where the individual deductible is $200 and the family deductible is $500, the family deductible would be
  satisfied by the following situation in chronological order.

  Family Member #1
  Incurs a bill for $300                                             Meets $200 individual deductible
  The remaining $100 is subject to their coinsurance

  Family Member #2
  Incurs a bill for $400                                         + Meets $200 individual deductible
  The remaining $200 is subject to their coinsurance             = $400 of the $500 family deductible is met

  Family Member #3
  Incurs a bill for $200                                         + $100 meets the entire family deductible
  The remaining $100 is subject to their coinsurance             = $500 family deductible is met

  Family Member #4
  Incurs a bill for $300.
  The entire claim will be subject to their coinsurance.



                                                           43
Claims
In-network Deductibles:
In-network deductibles apply only to employers who offer Freedom Plan® DirectSM, Liberty Plan Direct ,     sm



Freedom Plan® Value OptionSM , Oxford MyPlanSM , Oxford Exclusive PlanSM, Oxford HSA DirectSM and Oxford
HSA ExclusiveSM. These plans also have an out-of-network deductible (see section below).

The in-network and out-of-network deductibles in these plans have to be satisfied independently before
medical bills are subject to either the in- or out-of-network coinsurance.



  For example:

  • Assume Joan has already satisfied her in-network deductible for this calendar year.
  • Joan then incurs a bill from Dr. Bob, an in-network physician. Dr. Bob bills us directly, and the bill is subject
   to Joan’s in-network coinsurance.

  • Now, Joan receives covered services from Dr. Smith, an out-of-network provider. Joan completes a
   HCFA-1500 Health Insurance Claim Form, and submits the claim form and the bill from Dr. Smith to us.
   Since Joan has not satisfied her out-of-network deductible, the bill will be applied to her out-of-network
   deductible.




Please note: Members are only responsible for their in-network deductible and coinsurance when receiving
covered in-network services. Participating physicians and other participating providers are not permitted to
balance-bill the member for any amount above the provider’s contracted rate.

Out-of-Network Deductibles:
Most billed amounts for covered services from an out-of-network provider are subject to a
deductible, coinsurance, and UCR. The member is responsible for any amount billed over the UCR.

Prior Carrier Deductibles (New Groups Only)
We will provide credit for deductibles paid to previous carriers under the following conditions:

• We will honor any prior deductibles paid to another health plan between January 1 and the effective date of your
 new policy;

• Deductible credit will only be given for the calendar year in which your policy first became effective and is only
 available to new groups;

• Deductibles will be credited in amounts equal to those applied to the previous health plan; and
• If our deductibles are higher than those of the previous plan, our deductible must be satisfied before benefits are paid.
• New hires to your company are not eligible for a deductible credit from their previous employer’s medical plan.
 Credit for deductibles is available only to employees who were enrolled under the health plan that your group had
 before coverage began.




                                                           44
Claims
How to Receive Credit for Previous Carrier Deductibles
We will not obtain deductible information from your previous carrier. This is the responsibility of the member. To
obtain credit for deductibles paid to a previous carrier, members should:

• Obtain Explanation of Benefits forms from the previous carrier showing the amounts of the deductibles applied;
• Complete a Prior Carrier Deductible Form (members can download this form on www.oxfordhealth.com               www

    or call Customer Service to request the form); and

• Within 60 days of your policy’s effective date, submit these forms to:
      Oxford
      Attn: Deductible Credit Center
      P.O. Box 7081
      Bridgeport, CT 06601-7081


Understanding Coinsurance and Out-of-Pocket Maximums
• The basic principles for coinsurance and out-of-pocket maximums can be applied to plans that have
    in- and/or out-of-network benefits.

• Members enrolled in plans that have both in- and out-of-network deductibles and coinsurance need to satisfy
    the in- and out-of-network deductibles, coinsurance, and out-of-pocket maximums independently.

• Once a member’s deductible is met, claims will be reimbursed subject to coinsurance up to the out-of-pocket
    maximum specified in the Summary of Benefits.

• The deductible and coinsurance percentages applied to the member’s claims are not based on billed charges.
    They are based on either the in-network provider’s contracted rate (in-network charges only) or on the
    charges deemed usual, customary and reasonable (UCR) by us (out-of-network charges only).
	       O
      •		 nly	the		contracted	rate	or	UCR	amount	is	applied	to	the	member’s	deductible.	
	       O
      •		 nce	the	member’s	deductible	has	been	met,	then	the	coinsurance	percentage	of	the	contracted	rate	or	
        UCR is applied to the out-of-pocket maximum.
	       P
      •		 lease	note	(out-of-network	only):	The	member	is	always	responsible	for	paying	any	charges	above	the	UCR	
        amount for out-of-network providers. See Usual, Customary and Reasonable Allowances.

• A member’s out-of-pocket maximum represents the amount of money in deductible and coinsurance that an
    individual and/or family must pay before claims are reimbursed by us at 100 percent of the contracted rate
    (in-network charges only) or UCR allowances (out-of-network charges only). Members should refer to the
    Summary of Benefits for their coinsurance percentage and out-of-pocket maximum.




                                                          45
Claims
   The information in the following two examples are based on this member profile.

             Single deductible:                                  $200

             Single out-of-pocket maximum:                       $1,200
             Family deductible:                                  $500
             Family out-of-pocket maximum:                       $3,000
             Coinsurance:                                        80%/20%
             Deductible + coinsurance =                          Out-of-pocket maximum



Example #1 illustrates how the following instance can be applied during an
in- or out-of-network situation.
• Teri receives a bill for $100 from Dr. Smith.
• The contracted rate (in-network) or UCR (out-of-network) for that procedure is $75.
• Assuming that Teri has met her applicable single deductible of $200, then we are responsible for 80% of the
 contracted rate or UCR (80% x $75 = $60).

• Teri is responsible for 20% of the contracted rate or UCR (20% x $75 = $15). For out-of-network plans only: Teri
 is also responsible for the difference between the billed amount and the UCR ($100 – 75 = $25).




                                                                 In-network                     Out-of-Network
   n
       Billed amount                                              $ 100                               $ 100
   n
       Contracted rate/UCR                                        $ 75                                $ 75
   n
       We pay 80% coinsurance                     (80% x $75)     $ 60                                $ 60
   n
       20% coinsurance amount                     (20% x $75)     $ 15                               $ 15
   n
       Amount above UCR (out-of-network only)                      N/A                  ($100 – $75)+$ 25
   n
       Total amount Teri owes Dr. Smith                           $ 15                               $ 40
   n
       Single out-of-pocket maximum                               $1,200                              $ 1,200
   n
       Accumulated deductible + coinsurance       ($200 + $15)    $ 215                             – $ 215
   n
       Remaining out-of-pocket maximum                            $ 985                               $ 985




                                                          46
Claims
Example #2 illustrates how the following instance can be applied during an in- or
out-of-network situation.
• Teri incurs a second bill from Dr. Smith for $8,000.
• The contracted rate or UCR is equal to the billed amount. We pay 80% of the contracted rate or UCR (80% x
 $8,000= $6,400).

• Again, Teri is responsible for 20% of the contracted rate or UCR. For out-of-network plans only: Teri is also
 responsible for the difference between the billed amount and the UCR ($8,000 – $8,000 = $0).

Since the amount owed to Dr. Smith exceeds Teri’s out-of-pocket maximum, she is responsible only for the
remaining $985 of her out-of-pocket maximum, and we are responsible for the $615 difference.

Now that Teri has met her out-of-pocket maximum (deductible + coinsurance), we are responsible, from this point
forward, for 100% of the contracted rate for all in-network procedures, or UCR for all out-of-network procedures or
visits incurred for that calendar year. Teri is still responsible for amounts above the UCR.


                                                                      In-network                 Out-of-Network

  n   Remaining out-of-pocket maximum                                     $ 1,985                       $ 1,985

  n   Second billed amount from Dr. Smith                                 $ 8,000                       $ 8,000
  n   Contracted rate/UCR                                                 $ 8,000                       $ 8,000

  n   We pay 80% coinsurance                             (80% x $8,000) $ 6,400                         $ 6,400

  n Teri pays 20% coinsurance                            (20% x $8,000) $ 1,600                      $ 1,600
  n Amount above UCR (out-of-network only)                                 N/A        ($8,000 – $8,000)+
    $0
  n Total amount Teri owes Dr. Smith                                      $ 1,600                       $ 1,600

  n Remaining out-of-pocket maximum
    Teri needs to meet                                                    $ 1,985                       $ 1,985
  n Teri’s 20% coinsurance amount                                     -   $ 1,600                   -   $ 1,600
  n Remaining out-of-pocket maximum                                       $0                            $0
    (Teri has now met her out-of-pocket maximum)

  n Teri has met her out-of-pocket maximum,
    and we pay the remaining $615
    to Dr. Smith                                         ($1,600 – $985) $ 1,615                        $ 1,615
  n Teri pays Dr. Smith                                                   $ 1,985                       $ 1,985



Important Points to Remember:
• The member’s deductible and coinsurance are reset to zero at the beginning of every calendar year for most groups.
• Members with out-of-network coverage will remain responsible for the coinsurance level of the UCR until his or
 her out-of-pocket maximum or the family out-of-pocket maximum for that calendar year is met.

• Members with out-of-network coverage are always responsible for any difference between the UCR and billed
 amount, regardless of whether the out-of-pocket maximum has been met.



                                                           47
Claims
Coordination of Benefits (COB)
If a spouse or dependent becomes a member while also covered by another health insurer, one insurer will be
considered primary, while the other will be considered secondary. All claims must first be evaluated by the primary
health insurance carrier before they are submitted to the secondary carrier.

It is essential for us to know about any duplicate coverage information, even if it is for only one family member. COB
questionnaires are mailed to members who fail to adequately complete the “other carrier” question on the Member
Enrollment Form.

Please see your Certificate of Coverage for specific details regarding our coordination of benefits policies with
other insurers.


Oxford as the Secondary Health Insurance Carrier
When we are the secondary carrier for a member, all claims for health care services must first be evaluated by the
primary insurer before benefits will be considered. This includes all claims that are covered by:

• Another health insurance company
• Auto insurance
• Workers’ compensation insurance
For example, a member’s spouse is insured by both us and XYZ Health. XYZ Health is the primary carrier, and we
are the secondary carrier. The member’s spouse receives treatment from a dermatologist. First, the claim must be
processed by XYZ Health. Then, an Explanation of Benefits from XYZ Health needs to be submitted to us, along
with an itemized bill, for us to determine payment.


Determining the Secondary Health Insurance Carrier
If a person is covered by more than one plan, we make a determination of which plan is primary based on criteria
that may include the insured’s status as either subscriber, spouse/partner, or dependents, their marital status and
the presence of a divorce/court decree and date of birth. In addition, if the other carrier is Medicare, criteria may
include their working status as either working, retired or disabled and the size of the group. Please refer to your
Certificate of Coverage for more information.




                                                          48
Claims
Submitting a Claim When Oxford is the Secondary Health Insurance Carrier
In order for us to consider a claim as the secondary insurer, members should attach an Explanation of Benefits
(EOB) from the primary insurer, along with a completed HCFA-1500 Claim Form and original provider invoice. For
instructions on how to complete a claim form, see the section, “What to Complete on an HCFA-1500 Claim Form.”


Health Reserve Account Claims
The following section only applies to employers who have Oxford MyPlanSM.

Important Note:

The Oxford MyPlanSM Health Reserve Account is based on a health reimbursement arrangement (HRA), which is
subject to the requirements of the Internal Revenue Code. Groups may want to consult a tax advisor regarding
these accounts. Neither Oxford Health Insurance, Inc., Oxford Benefit ManagementSM (OBM) or any other affiliate of
Oxford Health Plans, LLC shall act as a fiduciary for the employer group. Information in this document is subject to
change without notice.


Oxford MyPlanSM Coverage
Oxford MyPlan covers in-network preventive care at 100%, with no deductible. Oxford MyPlan has a deductible
for both in- and out-of-network services. Generally, this deductible applies to all covered services, unless your plan
includes an office visit copayment. If your plan has in-network deductibles for most services, members will need to
pay attention to what type of care is needed and how much it will cost. Members are in charge of where and when
they access care and when they incur out-of-pocket expenses.


Oxford MyPlan Health Reserve Account
The Health Reserve Account helps members pay for covered out-of-pocket expenses that fall under the deductible
or coinsurance provisions of their plan.

Understanding what health care really costs is a key component of the Oxford MyPlan. After members receive care,
they will receive a detailed EOB report that shows exactly how much their care costs, and calculates how much is
covered under the deductible.

Members will use the EOB to apply for reimbursement from their Health Reserve Account. Since they will be
drawing on either their Health Reserve Account or personal funds until they meet the deductible limit, they will want to
control their spending carefully. After exhausting the Health Reserve Account funds, members are responsible for the
remaining deductible. The employer is solely responsible for funding the Health Reserve Account.


Oxford MyPlan in Action
To help you better understand how the Health Reserve Account works, we have created two member profiles and
outlined typical medical expenses. Member experiences and cost shares may be different from the examples and will
be based on their specific choices and plan design. These figures are for illustrative purposes only.




                                                          49
Claims
Example #1

Jane Smith is single and living in Tarrytown.
Oxford MyPlan deductible (single): $1,000
Health Reserve Account: $500

• Jane sees an in-network allergist. The allergist sends the claim to us as he/she normally would.
• We adjudicate the claim, approving the contracted rate of $135.
• We send an EOB to both Jane and her allergist stating that $135 has been applied to Jane’s deductible.
• Jane has two choices for using her Health Reserve Account:
 1. She may assign payment from her Health Reserve Account directly to her allergist. By sending her EOB
    to us, she will generate a $135 payment from her Health Reserve Account to her allergist.
 2. She can pay her allergist the $135 directly, and submit an Oxford My Plan Health Reserve Account
    Claim Form to us, along with her EOB and a receipt from the allergist. This will generate a $135
    payment from the Health Reserve Account directly to Jane.

• We will debit the Health Reserve Account, leaving a balance of $365 for future expenses.
Jane has participated in the actual health care cost transaction but, because of the Health Reserve Account,
she has not incurred any out-of-pocket expense.


Example #2

Eddie Lopez is married with two children and lives in Queens.
Oxford MyPlan deductible (family): $2,000
Health Reserve Account: $1,000

• Eddie’s son John cuts his finger, and it looks like he’ll need stitches. Eddie doesn’t know if he should go
 to the urgent care center or the hospital emergency room (ER) just around the corner. Because his Oxford
 MyPlan has an in-network deductible, he knows his Health Reserve Account will cover his costs, up to the
 first $1,000.

• Eddie realizes that John is in no immediate danger. Because he knows that visits to urgent care centers
 typically cost less than visits to the ER, Eddie decides to take his son to the urgent care center.

• We adjudicate the claim from the urgent care center at $145, send an EOB to both parties, and apply
 $145 to Eddie’s deductible.

• Eddie may choose to assign the payment directly to the urgent care center, or make a payment himself and
 submit the receipt with the EOB and claim form to us for reimbursement.

• Eddie’s Oxford MyPlan Health Reserve Account balance is adjusted to $855.
Eddie has taken a first step at understanding how health care decisions can impact his Health Reserve
Account. Eddie has become a more engaged health care consumer. And by choosing the more efficient care
choice, he has used his Health Reserve Account dollars wisely and hasn’t incurred out-of-pocket costs.




                                                      50
Claims
Making Oxford MyPlansm Work for You
How Oxford MyPlan Medical Claims Work
Generally, members will not pay the provider at the time of service (certain plans include copayment provisions for
physician office visits). After a member’s office visit, the doctor or other provider will submit a claim to us.

Here’s what happens next:

• We adjudicate the claim and determine which amounts should be applied to the deductible, coinsurance, or
 other benefits.

• We send an Explanation of Benefits (EOB) to the provider and to the member explaining how much the member
 owes the provider, if applicable.

• The in-network provider will then bill the member for any amounts due under their deductible and coinsurance.
Out-of-network claims are different. The out-of-network claim will be adjudicated by us, and the approved charges
may be reduced based on the member’s usual, customary and reasonable (UCR) level of reimbursement. The
member may still owe the provider charges beyond the deductible and coinsurance charges outlined on their EOB.
Charges above the UCR are not eligible for reimbursement from the member’s Health Reserve Account.


How Members Use Oxford MyPlan Health Reserve Account
to Pay Claims
After receiving care, members will receive an EOB from us that illustrates which charges may be applied to their
deductible or coinsurance. The deductible amounts are eligible for reimbursement from their Health Reserve
Account. Here’s what members can do:

Option 1: Automatic Payment to the Provider

• The member submits the EOB and an Oxford MyPlanSM Health Reserve Account Claim Form to the Oxford
 MyPlan address listed on the form. A sample of the form can be seen on the following page. The member selects
 the “Assignation of Payment” box on the form to indicate that he/she wants the payment to go directly to the
 provider. All forms are available at www.oxfordhealth.com. www

• We will send payment for all eligible expenses (up to the remaining Health Reserve Account balance) directly to
 the provider.

• The member will receive a statement confirming that this payment has been made.
Option 2: Pay the Provider and Get Reimbursed

• After receiving an EOB from us, the provider will send the member a bill for the approved charges, which should
 match the amount indicated on the EOB. The member should pay the provider the approved amount. The member
 should keep a copy of the bill and get a receipt from the provider.

• The member should submit the EOB, the receipt, and an Oxford MyPlan Health Reserve Account Claim Form to
 the Oxford MyPlan address as indicated on the form.

• We will send payment for all eligible expenses (up to the remaining Health Reserve Account balance) directly to
 the member.




                                                          51
Claims
Oxford MyPlan Health Reserve Account Claim Form
Important things to remember:

• Members need to indicate in the ‘Assignation of Payment’ box to whom the payment should be sent.

• Members need to submit a copy of their EOB and a receipt (if they are asking to be reimbursed) with the claim form.




                                                         52
Claims
What Expenses are Eligible for Reimbursement?
The Oxford MyPlan Health Reserve Account may be used to reimburse all covered charges applied to the deductible
                   sm



or applicable coinsurance costs. Members should refer to their Summary of Benefits for information specific to their plan.


What Expenses are Not Eligible for Reimbursement?
The Oxford MyPlan Health Reserve Account does not reimburse money spent on the following services:
• Pharmacy copayments or deductibles
• Out-of-network charges in excess of the allowed amount
• Denied claims
• Dental, vision, or other services not covered by the insured’s health plan
• Office visit copayments (where applicable)


How Pharmacy Claims Work
Most Oxford MyPlan plan designs include pharmacy coverage. That pharmacy coverage is independent from the medical
benefits, and may include a separate deductible. Pharmacy charges are not eligible for reimbursement under the medical
deductible. Our pharmacy plans provide many incentives to use cost-effective medications, and deductibles are generally
more moderate than medical deductibles. Consult the Certificate of Coverage for full pharmacy benefit details.


How Members Get Information on Deductibles or Oxford MyPlan Health Reserve
Account Balances
The Oxford MyPlan Special Services team is available during business hours to give members information regard-
ing their balance. The toll-free phone number for Oxford MyPlan Special Services can be found on the member ID
card, or members can call 1-800-588-8621.




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