How to read your Health Benefits Statement

We will send you a Health Benefits Statement every month in which you have a claim processed for health care services you received.

The Health Benefits Statement gives you information about how much the provider charges for the services, how much Fallon pays and how much you are responsible for paying.

What your statement tells you:

Dates of service
The day or days you were provided the service

Service description
A short description of the service you received, such as laboratory service if you had blood drawn for testing

Your provider charged
The amount that your provider billed for the service

Fallon discount
The difference between what the provider billed and the allowed amount. It’s the discount you get for being a Fallon member.

Fallon allowed amount
The amount that a provider is allowed to charge for a service. This amount is negotiated between Fallon and your provider.

Amount Fallon paid for this claim
If Fallon paid for any or all of the claim, that amount will be reflected.

Copay amount
If you paid a copayment the day you had the service, that amount will be reflected. Definition of copayment

Coinsurance amount
If you paid a coinsurance the day you had the service, that amount will be reflected. Definition of coinsurance

Amount applied to your deductible
The amount that you are responsible for paying. A bill from your provider should be for this amount, minus any coinsurance or copay amount you already paid at the time of service. Definition of deductible

Amount not covered
Any amount you may be responsible for if you have exceeded the maximum benefit limit for a covered service or may incur for not following medical management procedures. This amount does not count toward your deductible.

What you owe
The amount that you owe for the service. This includes any copayments, coinsurance and deductible that you are responsible for.

Out-of-pocket maximum (OOPM)
The dollar amount that limits how much you have to pay for services during the year. Your OOPM may only apply for certain services. Definition of out-of-pocket maximum

For more information

FCHO logo - small version myFallon

  • Check your benefits and claims
  • Access plan documents 
  • Use interactive health tools

Go to myFallon ►

Got questions?

We're here to help!

1-800-868-5200 
Monday, Tuesday, Thursday, and Friday from 8 a.m. to 6 p.m. and Wednesday from 10 a.m. to 6 p.m.
(TRS 711)

cs@fallonhealth.org

We'll be happy to answer your questions!