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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 an employer health plan model that sets maximums for what the Plan will pay for covered medical services to any provider you choose.

 

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. Please contact your Human Resources team for additional information on the changes to your Plan.

 

How do I find a doctor or facility?
You can find, compare, and contact top-experienced doctors who are more likely to accept RBP plans using a feature called RBP Guidance. RBP Guidance allows you to navigate your RBP plan with ease. Search by a condition, procedure, doctor’s name, location, or hospital and within seconds RBP Guidance shows high quality options that have a strong history of accepting RBP plans. Created with our partner, Amino, RBP Guidance can be accessed through the Amino website or app. RBP Guidance search results do not guarantee coverage and may be subject to change.

 

Can I see any doctor I want?
Yes, you may elect to see any doctor you would like. Doctors will be reimbursed according to the Plan limits based on the reference-based pricing model. Please verify that your elected provider will accept your Plan. If the admission staff has any questions about your benefits or coverage, direct them to the Plan administrator customer service team using the telephone number on your ID card.

 

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.

 

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. Please contact for your Plan administrator for assistance should you need to file an appeal.