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How much will I be reimbursed?

The Pivot Health short term medical claims reimbursement system is set up to guarantee that no member will be responsible for a balance bill due to the discount taken for charges above the Medicare Reference Pricing amount, subject to the terms outlined in the certificate of insurance. 

This insurance plan reimburses medical providers based on a percentage above Medicare allowable amounts, paying:

  • 150% of Medicare allowable amount for medical facilities 
  • 125% of Medicare allowable amount for physician claims

When bills are received, they are repriced according to these percentages of the Medicare allowed amounts, based on the Medicare fee schedule. Payment is made to the provider based on this amount and the reduction shown as a discount by the provider.

If a provider wishes to review and discuss the allowed amount or initially objects to the reimbursement amount, the provider is connected with the repricing vendor. The repricing vendor is authorized to negotiate a settlement.

In addition, providers are contacted proactively, to confirm that they are accepting the reimbursements and not shifting costs to members.

Updated on October 12, 2020

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