You receive the HSS in the mail and can also view it by logging in to bcbsri.com and clicking on Claims.

After you see your provider, they send a claim for your service to BCBSRI. Once BCBSRI processes that claim, it will show up on your HSS. Because claims are not always submitted to BCBSRI right away, you may see services listed that you received weeks or even months earlier. You’ll only receive an HSS if you share in the cost of a healthcare service.

Here you’ll see a total of all services listed on the HSS for you and your dependents under age 16. That could be one service or 10+.

This is the total of the charges on the HSS from all of your doctors, hospitals, and other providers. You’d be responsible for this amount if you didn’t have BCBSRI insurance. The actual amount you owe is usually less when your providers are in the BCBSRI network.

Since BCBSRI negotiates discounted rates from providers in our network, you pay less for your services. This is often a significant savings. Here you can see how much you saved on services listed on the HSS.

This is the total amount that BCBSRI paid toward your healthcare services.

If you have coverage from another health plan, those reimbursements will lower what you owe.

Here is the total amount that you owe to the providers listed on the HSS. If more than one service is listed, you’ll likely receive separate bills for each. Each charge is listed separately later in the HSS. (If any services you received weren’t covered by BCBSRI, those costs also will be included here.)

This shows the amount you saved by using providers in the BCBSRI network. Your savings can add up!

These charts show how much you’ve paid toward your deductible(s) and out-of-pocket maximum(s) as well as how much you have remaining.

  • Your deductible is the amount you pay each year for certain services before your health plan starts to pay. Not sure what services apply to the deductible? Log in to bcbsri.com and click on Benefits.
  • Your out-of-pocket maximum is the most you’ll have to pay for healthcare services in a year.

You may have separate deductibles and out-of-pocket maximums for services received in and out of the BCBSRI network. Although it is not shown on this example, you may also have separate deductibles and out-of-pocket maximums for yourself and your family.

Starting here, you’ll find each individual claim from a healthcare provider. Have a dependent under age 16 on your plan? Their services will be listed underneath your services.

This is claim line #01 because it is the first claim listed.

You received services from the provider on the date shown.

Here you’ll find a brief description of the service you received.

You’re sharing in the cost for this service because you’re responsible for one or more of the following:

  • Deductible – What you pay for certain services before BCBSRI pays for them
  • Coinsurance – The percentage you pay for specific services, such as 20%
  • Copayment – A set dollar amount you pay for specific services, such as $25

This amount should match the amount on the bill you receive from your provider. If it doesn’t, please call your provider or BCBSRI Customer Service.

Welcome to your BCBSRI Healthcare Services Summary (HSS)!

You may know it better as the "This is not a bill" document. You receive it any time you or a dependent under age 16 share in the cost of a healthcare service. While the HSS is not a bill, it shows you how much your doctor, hospital, or other healthcare provider will charge when they send the bill for your medical services.

Want more detail on what's included? Simply click on the highlighted text for an explanation.

Blue Cross and Blue Shield of RI

ATTN: Membership - 00000
Blue Cross & Blue Shield of RI
500 Exchange Street
Providence, RI 02903-2699

Blue Cross and Blue Shield of RI

Forwarding Service Requested

BCBSRI.com
(401) 459-5000 or 1-800-639-2227
TDD: 711

BCBSRI.com
(401) 459-5000 or 1-800-639-2227
TDD: 711

BCBSRI Member ID #: ZBH0000000000
Statement Page 1 of 3
Statement Date: 12/31/2017

BCBSRI Member ID #: ZBH0000000000
Statement Page 1 of 3
Statement Date: 12/31/2017


Healthcare Services Summary

This statement shows healthcare services you recently received, including what BCBSRI paid your healthcare providers and your share of the costs for these services. This is not a bill.


This includes copays, coinsurance, and/or deductibles, which you may have already paid.
Your healthcare provider(s) may bill you this amount and you must pay the provider(s) directly.

You saved 29% by using BCBSRI network discounts!

Plan Benefit Period: 01/01/2017 - 12/31/2017

Your Individual In Network Deductible

$750 Max

$750 Max

$162.60 Met
$587.40 Remaining

$587.40 Remaining

Your Individual In Network Out of Pocket Maximum

$1,700 Max

$1,700 Max

$162.60 Met
$1,537.40 Remaining

$1,537.40 Remaining

Your Individual Out of Network Deductible

$3,000 Max

$3,000 Max

$0.00 Met
$3,000.00 Remaining

$3,000.00 Remaining

Your Individual Out of Network Out of Pocket Maximum

$6,800 Max

$6,800 Max

$0.00 Met
$6,800.00 Remaining

$6,800.00 Remaining


Date(s) of Service: 11/21/2017
Claim Received: 11/24/2017
Claim Number: E000000000 00
Healthcare Provider: SMITH, JOSEPH

Claim
Line #
Date of
Service
Service(s) Explanation(s) for Cost Your Cost
01 11/21/2017 Established patient office or other outpatient visit, typically 15 minutes COPAYMENT $30.00

Your total costs for this claim $30.00
Claim Line # 001
Date(s) of Service 11/21/2017
Service(s) Established patient office or other outpatient visit, typically 15 minutes
Explanation(s) for Cost COPAYMENT

Your total costs for this claim $30.00