Understanding my insurance

Insurance can be confusing and overwhelming. These topics will help you understand how to use your insurance so you can focus on the things that matter: your life and your loved ones.   

Here are some important terms to know as you use your health plan: 

Deductible  The amount of covered medical costs you must pay each calendar year before the plan begins to pay its share of allowable charges. After you meet your deductible, your insurance will begin covering part of your medical costs.

Note: If you have a zero deductible plan, your health plan begins covering services right away. 

Coinsurance  If you reach the deductible, then you begin to pay coinsurance up to a capped amount called the coinsurance maximum. That means you only pay a portion of your health care costs, and the plan pays the rest. The coinsurance you pay depends on whether you use in-network or out-of-network providers. 

Coinsurance maximum The maximum amount that you could pay each year in coinsurance amounts for covered services. If you seek care with out-of-network providers, only the allowable charge applies to the coinsurance maximum.

Out-of-pocket maximum 
The maximum amount you could pay each year in deductibles, coinsurance and/or copayments for covered services and supplies. If you reach the out-of-pocket maximum, the plan pays 100 percent of the allowable charges for your covered medical expenses for the rest of the calendar year.

Quick tip! Your out-of-pocket maximum equals your deductible plus your coinsurance maximum.

Allowable charges This refers specifically to out-of-network costs. Your plan has agreed to pay specific amounts for different providers, services, etc. This is the allowable charge your plan will pay toward an out-of-network provider. You are responsible for paying any amount above that agreed-upon amount (the allowable charge).  

Your health care expenses depend on the following:

  • If you have not met your annual deductible, you will pay 100 percent of the cost.

  • If you have met your deductible and are paying coinsurance, you will pay a percentage of the cost for in-network providers.

  • If you have reached your coinsurance maximum, you pay 0 percent for in-network eligible health care expenses for the rest of the year. If you utilize out-of-network providers, you will always be responsible for any billed charges above the plan’s allowable charge, so be sure to choose in-network providers to limit your costs.

Note: Deductibles, coinsurance, and out-of-pocket maximums vary by plan. To learn more about your specific plan (including any limitations and exclusions), go to the Summary Plan Description.

To simplify the process for paying for health care expenses and to reduce your risk of overpayment, make paying medical bills part of your normal bill paying routine. Here are some more helpful tips: 

  • After you receive a medical bill or Explanation of Benefits (EOB), put it wherever you keep your “to be paid” bills. Pay this along with all other routine monthly payments.  

  • If you don’t have all the pieces you need to pay for a particular expense (for example, an EOB and/or a provider’s bill), set the bill aside to pay later after you have the necessary documentation. 

Quick tip! Set a reminder for yourself to contact your health provider if you haven’t received all the necessary documentation within a week of the bill’s due date. 

  • Be consistent with your payment method. Use the same payment method each time you pay for your health care expenses, whether that's via your personal funds or your Health Savings Account (HSA) (using your Fidelity Debit Card or online).

  • Be careful not to overpay from your HSA. Several actions may trigger an overpayment, including: 

    • You pay your provider before the bill is processed through your health plan.
    • You use multiple ways to pay medical bills with your HSA (for example, you pay some bills using your Fidelity debit card, and others you pay online via NetBenefits.com).

 

Tip: When paying a new charge (eg: a new specialist you’ve never visited before), consider paying out of pocket if you can, and then reimbursing yourself with your HSA once the total amount you owe is confirmed. It’s difficult to put money back into an HSA, so you want to avoid needing to do this if possible. 

In-network care

When you receive in-network care, your provider should submit a claim directly to your health plan. You will receive an EOB from your plan, which includes a summary of services and associated costs. If you have a deductible, its status will also be included.

After the claim has been submitted, your provider will send you a bill for any care that isn’t considered preventive. To find out what is considered preventive, see the Summary Plan Description.

Before you pay a bill from your provider or hospital, it's a good idea to compare it to the Explanation of Benefits (EOB) to ensure the amount due is correct.

Out-of-network care

If you visit an out-of-network provider, you’ll need to confirm if they will submit a bill to your health plan, or if you’ll need to submit the claim yourself. Be sure to submit the claim form within 30 days of the service.

Reminder: Only the allowable charges will be applied to your deductible (if you have one) or coinsurance maximum. This means that any charge that exceeds what your health plan said it would pay one of their in-network providers for the same service you received will not count toward your deductible or coinsurance maximum. 

Select your medical plan below for claim form instructions.

Premera

Download your claim form from the plan documents and tax information page.

You'll need to have your Premera ID card and the bill from your provider's office handy. Fill out the form, including all the following information:

  • Your name and the member's name
  • Identification numbers shown on your identification card (including the alpha 3-digit, or MSJ)
  • Provider's name, address, and tax identification number
  • If you are seeking secondary coverage from the Microsoft health plan, information about other insurance coverage related to the claim at hand, including a copy of their Explanation of Benefits (EOB), if applicable
  • If treatment is because of an accident: the date, time, location, and brief description of the accident
  • Date of onset of the illness or injury
  • Date of service
  • Diagnosis or ICD-9 code (this information can be found on the provider bill)
  • Procedure codes (CPT-4, HCPCS, ADA, or UB-92) or descriptive English language for each service (this information can be found on the provider bill)
  • Itemized charges for each service rendered by provider

Send your completed form to Premera in one of the following ways:

Mail to the following address:

Premera Blue Cross 
P.O. Box 91059 
Seattle, WA 98111-9159

Send an email message to Premera Claims

Fax to (800) 676-1477

Surest

You can complete the Surest claim form online here or download your claim form from the plan documents and tax information page.

You'll need to have your Surest ID card and the bill from your provider's office handy. Fill out the form, including all the following information:  

 

  • Your name and the member's name 
  • Identification numbers shown on your identification card 
  • Date of service 
  • Place of Service Code 
  • Type of Service 
  • Procedure Codes (CPT, HCPC) with any applicable modifiers 
  • Units for each procedure code 
  • Diagnosis codes 
  • Charges for each service (or total charges if bundled) 
  • Billing and/or rendering provider: first and last name and NPI, address information, provider's TIN and signature, and the date 

 

Send your completed form to Surest to the following address: 

Surest 
P.O. Box 211758 
Eagan, MN 55121 

Questions? Contact Surest Member Services at (866) 222-1296

 

 

Learn more

Minimizing my medical expenses

Health plan comparison

Plan documents and tax information

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