Submitting claims

Explanation of benefits

If you have a financial responsibility after you use your coverage from us, you will be issued an explanation of benefits (EOB). Your EOB is not a bill. It is a breakdown of services used, amount charged by the provider and your financial responsibility to pay toward deductibles or coinsurance. You can see your prior EOB documents any time by logging in to your member portal.

Making payments

Paying your premium

If you are one of our individual and family plan members and your premiums are not auto-withdrawn from your paycheck, you have access to a number of convenient ways to pay your monthly premium. We can accept online payments as well as payment through the mail.

Paying for medical services

When you are seen at a clinic location for services, you will often have the option to pay an applicable copay upon check-in. Your clinic will bill you for any deductibles for which you may be responsible. The clinic will send you a bill for any copay charges not paid at the time of service or any coinsurance for which you are financially responsible. When you receive a bill this way, you may send in a check or provide your credit card information on the payment form and send it back to us. You may also make the payment online through MyChart.

How to submit a claim

In most cases, claims are submitted directly to us by the providers or clinics. On occasion, if you’re traveling out of the area or have a college-age dependent, for example, it may be necessary for you to submit a claim for reimbursement (PDF). 

When submitting the claim and the form, be sure you:

• Send an itemized bill from the provider of service.  Requests must include the following:
  • Full patient name
  • Member ID
  • Procedure code(s)
  • Diagnosis code(s)
  • Date of service
  • Requested reimbursement dollar amount
  • Valid receipt of payment which must contain:
    • Date of service(s)
    • Place of service(s)
    • Billed amounts for each code
• If services were received outside of the United States, you will need to submit the original bill along with an itemized bill that has been translated into English and indicate the appropriate currency exchange rate at the time the services were received. 
• Send the bill within 60 days after the services are received to: Medica Central Health Plan, Attn: Claims Department, P.O. Box 56099, Madison, WI 53705.

If you have other health coverage that is the primary payer, you will need to send the EOB to us or your health care provider.

If you have questions, call Customer Care at 866-514-4194 (TTY: 711). Or you can call the number on the back of your member ID card. 

This information pertains only to our QHP plans.