*ID cards will vary in the location of this information. This sample ID is only provided to be a guide.
- This is the payor who is responsible to adjudicate (pay) your medical claims as repriced by the network (see B) in accordance with the patient's benefit plan design including: eligibility, deductibles, copays, etc.
- This is the network of hospitals, doctors, and other providers that are considered in-network for the patient's benefit plan. The network will reprice your claims as submitted by the provider to the contracted amount and forward them to the payor (see A) for payment.
- This is the patient's Family ID number under their benefit plan. Often, each member of the family will be assigned a suffix to this ID number to provide a unique ID for each member of the family.
- This is the Group Number to which the patient is assigned. The member's employer may have one or multiple group numbers set up with their Payor.
- Member Name is the patient's name and will often list the other members of the family that participate under their plan.
- Copayment Information is often provided that applies to the patient's benefit plan for common types of visits such as to a Primary Care Physician (PCP) or Specialist.
- This is the Payor's (See A) customer service number that you can call to receive answers to any questions you may have regarding the adjudication (payment) of your claim and what benefit levels apply to the services. The Payor can also verify the patient's eligibility prior to delivery of the service.
- If the patient must obtain precertification for a service before having it delivered, the provider or patient would call this number for the party who is responsible for the medical/utilization management for that patient.
- This is the Network's (See B) customer service number that you can call to receive information on a provider's participation in the network and product for which the patient is a member. The Network can also answer questions regarding the provider's contract with the network including contracted discounts applicable.
- This is where the provider should submit patient claims for processing (including network discount processing and claim adjudication by your payor). Depending on the arrangement determined by the Payor and the Network, either party may receive the claim first. It is important to direct the claim as stated on the Patient's ID card to ensure expeditious adjudication.
- If your office submits claims electronically, this is the appropriate party's electronic ID for claim submission.
- This is where additional information can be found for which network of providers applies for certain service areas if the patient is traveling outside of their primary network area. The provider will want to ensure that they understand which network applies for the services they are going to provide. If the interpretation of the medical card is still confusing, the Payor (See A) can be contacted to advise.