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Understanding Claims

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A claim is information sent to the LM HealthWorks Plan requesting payment for covered medical services that you or a covered family member received.

When you use an in-network provider, the provider will file a claim for processing and payment. In most cases, you pay nothing at the time of your visit. Some doctors may ask for payment at the time you receive services. Here’s what you should know — and what you can do — if this happens.

When you use an out-of-network provider, you may need to pay at the time of your visit. You are also responsible for submitting a claim to Aetna, the LM HealthWorks Plan administrator. You can call the LM HealthWorks Plan toll-free number at 1-877-458-4975 to request a claim form or you can download a claim form at Aetna Navigator®. Follow the instructions on the form and remember to include the provider’s original bill for services.

The plan pays a larger share of the covered expenses when you use in-network providers. To find in-network providers, use the Online Provider Directory »

How claims are paid

The plan typically pays 100% for routine preventive care services. For other services, if there’s a balance in your HealthFund, it will be used to pay the covered services and offset your annual deductible. If the HealthFund balance is depleted before the deductible is met, you pay for your care out of your own pocket until the deductible is met.

After the deductible is met, the LM HealthWorks Plan pays its share of the covered expense and you’ll receive a balance billing from your doctor or other care provider.

 

View Basics of the Plan for more details »

Where to find claim information

Members not yet registered with Aetna Navigator will receive a Monthly Claims Summary by mail.

Members registered with Aetna Navigator will receive an email notification each time a new Monthly Claims Summary is available online.

At the click of a mouse, you can access Aetna Navigator — 24 hours a day, 7 days a week — to view, download and print summary and detailed claim information.

The Monthly Claims Summary is your record of all claims activity for a specified period.

An Explanation of Benefits (EOB) statement is an online form that shows detailed information about claims. Look for the "Claim Explanation of Benefits" link under "Related Shortcuts" on your Aetna Navigator home page, or use the Claims and Balances tab to find EOBs for recent claims.

Key claim information provided on Aetna Navigator includes:

  • Identification of the medical services you received, who provided them and what the costs were for each service
  • How the costs were covered by the plan, and any balance you may be charged by your provider (remember, the EOB is not a bill)
  • Where you are in meeting your deductible — how much has been met and how much still remains
  • What expenses were paid from your HealthFund, and your current HealthFund balance

It is important that you carefully review the claim information to verify payments, deductibles, coinsurance and other financial aspects of the plan were applied correctly. Follow up on any questions right away with the provider or with LM HealthWorks Plan at 1-877-458-4975.

Some common questions and answers:

  • What are the most common things to understand about a claim? Learn more >>
  • How do I know if the claim information is accurate? Learn more >>
  • Will I receive claim information separately for my covered family members, and can I access their information? Learn more >>
  • What happens if a claim is pended (not paid) by the LM HealthWorks Plan? Learn more >>
  • What if I paid for a covered service that should have been paid by the HealthFund or by the LM HealthWorks Plan? Learn more >>

Need to know more?

If you have questions about your claim information or if you think something is missing or incorrect, you can:

Call the LM HealthWorks Plan at 1-877-458-4975 and a customer service representative will answer questions about how a claim was processed and paid.

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