How do I know if my claim was processed?
Members receive an Explanation of Benefits (EOB) by mail for each claim submitted to Memorial Hermann Health Insurance Company. The EOB provides detailed information regarding how the claim was billed by the provider and how your insurance policy benefits were applied to the claim. EOBs are also available online for your convenience through the member login. If you have questions about your claim or EOB, please contact Customer Service at (713) 338-4683 for assistance.
How can I check my deductible status?
After logging in with your username and password, you can find detailed information for your deductible amounts and benefit utilizations under the "Check Utilizations" section. You will also find that your Explanation of Benefits (EOB) notes the deductible status at the time of claim processing. Customer Service can also provide the deductible amounts and benefit utilizations at (713) 338-4683 during hours of operation.
I received a bill for my blood work. Why wasn’t this covered under my office visit copay?
Diagnostic tests (e.g., labs, X-ray, etc.) are subject to the applicable deductible and coinsurance outlined by your insurance policy. If the deductible has not been met at the time of claim processing, the Patient Balance will be applied towards the deductible. Once the deductible has been satisfied, you may need to pay a percentage of coinsurance; this amount is dependent upon your plan. The coinsurance amount paid will be applied towards your out-of-pocket expenses for the calendar year.
How do I know which labs are in-network?
In-network labs include Memorial Hermann Diagnostic Laboratories, LabCorp and Quest Diagnostics, Inc. Customer Service or our online provider search can be used to verify the in-network labs for reference. NOTE: It is important to ask your health care provider where your specimen will be sent for analysis; use of an in-network lab will ensure maximum savings.
I have prescription questions.
Please visit our Pharmacy Benefit FAQs. If you're question is not listed, call OptumRx Customer Services at 877-633-4461 for assistance with your prescription questions. You may also call our Customer Service team at (713) 338-4683 for assistance.
What is your service area?
Our service area comprises the following seven counties: Brazoria, Fort Bend, Galveston, Harris, Montgomery, Walker and Wharton.
If I am out of town and in need of medical attention, what do I do?
If you experience a medical emergency, please seek treatment at the nearest acute care hospital. For non-emergent situations, members can contact Customer Service at (713) 338-4683 or (888) 594-0671 (toll-free) to find the nearest Urgent Care facility contracted with our extended network, Healthy Directions. Members may also use the online provider search on our website.
How do I know when to go to Urgent Care or an Emergency Room?
ER visits should be limited to emergency situations for severe or life-threatening medical issues. Urgent care facilities offer treatment for less serious, yet pressing, medical concerns as well as needs typically addressed by a primary care physician. Urgent Care is less expensive than the Emergency Room and, more often than not, less time consuming.
What network would my child use while attending college out of area?
The network is PHCS Healthy Directions. Once the child returns home or is in the covered service area, he or she will be required to use our Select Network.
How do I add my newborn to my policy?
The baby is automatically covered for the first 31 days. To permanently add the child to the policy, the application should be completed and received in our office prior to the 31st day.
Where can I find out what my coverage/copayment will be for certain procedures?
You may refer to your certificate of coverage or you may call our Customer Service department at (713) 338-4683.
What is the difference between deductibles and copayments?
Deductible is the amount of covered expenses you must pay for covered services before benefits are available to you under the health plan.
Copayment is the amount that is due by the insured and payable to the provider of care. In most cases, copayments do not apply towards the deductible. Please refer to your certificate of coverage for more detail for your specific plan.
What is my out-of-pocket maximum and how does it work?
The out-of-pocket is the largest amount of money the insured pays toward the cost of your health care each year. After you have paid or met your deductibles, copayment and coinsurance to reach your out-of-pocket maximum, the health insurance company pays for all of the rest of your health care for that year.
How do I contact member services?
Call or email us today to learn more about your plan, claims, records and more.
Self-Funded Members: (713) 338-6535
Fully Insured Members: (713) 338-4683
Customer Service Email: firstname.lastname@example.org