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Frequently Asked Questions


Who is Zelis Healthcare?
Zelis Healthcare is a market-leading healthcare technology company providing integrated healthcare cost management and payments solutions to health plans and providers to address the rising cost of healthcare. Zelis is partnering with your health plan administrator to help improve your overall experience with your health plan.  Zelis offers many services to health plan clients including Reference Based Pricing solutions.


What is Reference Based Pricing (RBP)?
Reference based pricing (RBP) is a healthcare cost containment model that limits what a health Plan will pay for covered medical services to any provider you choose.  Under this model the Plan pays a percentage above the Medicare allowable which can save both you and the Plan money.


How is my health Plan changing? 
Your Plan has elected to replace its PPO network with a Reference Based Pricing (RBP) model for all providers.


How do I locate a physician or facility?
You will use the Zelis RBP Guidance tool to locate providers. This RBP Plan navigation tool was designed to help you easily locate providers in your area that are more likely to accept your Plan’s reimbursement rate as payment in full. While we take great care to make the directory complete and accurate, the listing of providers that are more likely to accept your Plan’s reimbursement rate as payment in full may change without notice.


Can I see any doctor I want? 
Yes, you may elect to see any doctor you would like. Providers will be reimbursed according to the Plan limits based on the reference-based pricing model. 


What is an Explanation of Benefits (EOB)?
An EOB contains several key pieces of information including the provider name, the date of service, the code used to bill a service, the fee charged by the healthcare provider, the allowed amount and your patient responsibility. Your EOB tells you what you owe for the services you received. Review your EOBs to determine your patient responsibility (what you owe) and then remit payment to the provider for the amount indicated on your EOB. If you have any questions about your EOB please contact your Plan Administrator.


Why was a Zelis discount applied to my claim? I don’t participate with Zelis.
Zelis reprices each claim according to the Plan limits. Remember to check your EOB to see what the Plan allowed and what you may owe as a cost-share.


What if the provider or facility sends me a bill?
You are responsible for your co-insurance and deductible. If you receive a bill from a provider, hospital or outpatient facility compare it to your EOB.  If the provider is billing you for more than what your EOB indicates you owe, please call Zelis at 877-259-3194. Once Zelis is aware of your balance bill, it will reach out to the provider on your behalf to resolve your claim.


The Employee Retirement Income Security Act of 1974 (“ERISA”) imposes duties upon the entity or individual(s) who have final decision-making authority over claims and appeals, called “fiduciaries.”  Because Zelis does not process claims or appeals for your Plan, Zelis is not a fiduciary of your Plan under ERISA.   Please review your Plan’s summary plan description for additional information on your Plan and the Plan’s fiduciaries.