From the payer perspective, a telltale sign that a member has been scammed is when there is no doctor’s visit associated with the DME claim. The companies often do not bill for medical assessments, opting to file claims strictly for prescriptions or medical equipment. In addition, these c...
A separate, or third-party, company that handles your health plan’s pharmacy benefit. A PBM processes and pays for your prescription drug claims based on the terms of your pharmacy benefit. Premium The ongoing amount that must be paid for your health plan. You and/or your employer usually...
An EOB is created after a claim payment has been processed by your health plan. It explains the actions taken on a claim, such as the amount that will be paid, the benefit available, discounts, reasons for denying payment and the claims appeal process. EOBs are available both as a paper...