How to read your Health Benefits Statement

If you have a plan with a deductible, every month in which you have a claim processed for health care services you received, we will send you a Health Benefits Statement.

The Health Benefits Statement gives you information about how much the provider charges for the services, how much Fallon pays and how much you are responsible for paying.

What your statement tells you:

Dates of service
The day or days you were provided the service

Service description
A short description of the service you received, such as laboratory service if you had blood drawn for testing

Your provider charged
The amount that your provider billed for the service

Discounted amount Fallon members pay
The amount that a provider is allowed to charge for a service. This amount is negotiated between Fallon and your provider.

Amount applied to your deductible
The amount that you are responsible for paying. A bill from your provider should be for this amount, minus any coinsurance or copay amount you paid at the time of service. Definition of deductible

Coinsurance amount paid
If you paid a coinsurance the day you had the service, that amount will be reflected. Definition of coinsurance

Copay amount paid
If you paid a copayment the day you had the service, that amount will be reflected. Definition of copayment

Benefit adjustment
Any amount you may be responsible for if you have exceed the maximum benefit limit for a covered service or may incur for not following medical management procedures. This amount does not count towards your deductible.

Amount Fallon paid for this claim
If Fallon paid for any or all of the claim, that amount will be reflected.

For more information

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