Each time you receive health care services, your provider or facility submits a bill (claim for payment) to Providence Health Plan. Providence Health Plan then processes the bill into a medical claim. We explain how your claim has been processed by sending you an Explanation of Benefits, often referred to as an EOB.
How to read your Explanation of Benefits
View a sample Explanation of Benefits (PDF) with definitions. The information on your Explanation of Benefits reflects:
- The amount your provider has billed for health care services you received.
- Any provider write-offs that were applied (for using a participating provider).
- How your medical benefits were applied.
- How much Providence Health Plan paid for the health care services received.
- Any remaining charges for which you may be responsible.
An Explanation of Benefits is not a bill. If you are responsible for any portion of the claim, the provider will send you a bill.
When you receive an Explanation of Benefits, check the information listed, including service dates, provider name and services received. Note: It’s possible to receive more than one Explanation of Benefits for the same service. For example, you may receive an Explanation of Benefits for lab work you received. You may also receive another for the pathologist who read your lab work results.
How we process your claim
Providence Health Plan processes the majority of medical claims automatically; however, in some instances, a claims processor will review your claim to determine payment. Several factors may affect the way your claim processes:
- Providence Health Plan may have an agreement with your participating provider to pay a reduced amount. Your Explanation of Benefits may also refer to this as “provider write-off.”
- You may have an annual deductible to meet before benefits are paid.
- You may owe a copay or coinsurance.
- The service billed may not be covered under your plan. (Refer to your Benefit Summary for your covered benefits or your member handbook for exclusions and limitations.)
- If you received services from a non-participating provider, you may be responsible for any amounts above Usual, Customary and Reasonable (UCR) charges.
Member responsibility (what you pay)
Your Explanation of Benefits explains any amounts not covered by the health plan. You are responsible for those amounts listed on your Explanation of Benefits as “Member Responsibility” (e.g., if you haven’t met your deductible or owe a coinsurance). Remember that an Explanation of Benefits is not a bill. If you are responsible for any portion of the claim, the provider will send you a bill.
Member materials online
When you enrolled with Providence Health Plan, you received information, including a benefit summary that highlights your covered benefits. The benefit summary includes information about any deductible, copays and coinsurance amounts for which you are responsible. Providence Health Plan also provides a member handbook. This document describes how to use your plan, as well as states the limitations and/or exclusions that may apply. These materials are also available online when you register for a myProvidence account.
When you register for a myProvidence account, you can access the following additional features:
- View claims history.
- View your benefit summary and member handbook.
- Order a replacement member identification card.
- Pre-register for services such as a surgical or hospital visit, or the delivery of your baby.
- Search for providers who participate with your specific plan.
How to contact us
Call Customer Service at 503-574-7500 or 800-878-4445 with any questions about your EOB. Please have your claim number (indicated on your Explanation of Benefits) available so we can assist you more quickly.