Your maximum out-of-pocket claim listing

Here’s how to read your maximum out-of-pocket (MOOP) claim listing.

How your MOOP works

Your maximum out-of-pocket amount is the most you can pay for covered health care in a 12-month period. It includes your deductible, eligible copays and eligible coinsurance payments. Your MOOP does not include your monthly premium payments.

Most payments that you make after receiving care go toward your MOOP. Once you pay the total of your MOOP amount, your plan will begin to pay for 100% of your covered benefits until the MOOP “resets” at zero in the next coverage year.

Reading your MOOP claim listing

Your claim listing (also called audit report) is a summary of the services you received and how they contribute to your MOOP amount. Use it to keep track of how much your providers have charged toward your MOOP amount.

  • Your listing may not show recent out-of-pocket payments
    Due to the length of time needed to process a claim, you may not see your most recent cost shares in your MOOP claim listing. California law AB1455 requires that contracted providers have no less than 90 days to send a claim. Then, the responsible entity has 45 business days to pay or deny the claim.

    Below is a helpful timeline to show how long it may take to process a claim.

Timeline
MOOP-claim-listing-Screenshot
  1. Member Name and ID: Your member ID is your Sharp Health Plan member ID number and shows you as the main contact on the account.
  2. Plan Name: Your plan name shows the plan you are enrolled in with Sharp Health Plan.
  3. Reported / Processed at Sharp Health Plan: The date your claim was processed in Sharp Health Plan’s system.
  4. Date of Service: The date you received your health care service from a provider.
  5. Name of Provider: The provider who conducted the health care service.
  6. Claim Number: The number assigned to a claim when received/processed by the health plan.
  7. Cost Share Responsibility Incurred: The cost share applied to the service, per your summary of benefits. Your cost share responsibility is based on the date your claim was processed by the financially responsible entity, not the date of service.
  8. Code Type: Shows the hospital, health plan, medical group, IPA or pharmacy that is financially responsible for the health care service. If a claim is marked with the letter “R,” it was sent back to the financially responsible entity to adjust the cost share as needed.
  9. Comments: Offers more information about your claim.
  10. Total: The sum of the cost share amounts. Use this number to find how close you are to meeting your MOOP amount.
  • TIP: If you have a medical claim that gets reprocessed, your refund will come from your provider; follow up with your provider’s office to make sure you receive your refund promptly.

    You may also qualify for a refund if you traveled out of the service area in the past 180 days (about six months) and received care or filled a prescription while you were away.

The big picture

Your maximum out-of-pocket amount is just one part of understanding how cost-sharing works in your health plan. Read more about how health insurance works, complete with a step-by-step example for calculating costs.