After you see your doctor, he/she will bill your insurance company. For HMO patients who belong to Physicians Medical Group of San Jose, your doctor will bill Physicians Medical Group of San Jose’s management company, EXCEL MSO.
With respect to out of pocket expenses, you are responsible for your co-pay; or if you have deductible for your health plan, your doctor may bill you. Your co-pay and plan information is generally printed on your individual Insurance ID card. Please also refer to your Evidence of Coverage (EOC) provided to you by your employer or health plan.
When you should contact Member Services (Applies to PMGSJ HMO Members)
In the event, you get a bill for the full amount, and your copay has been collected at the time of service, please call our Member Services Department at (408) 937-3642 (TDD/TTY 711) or toll-free at (833) 923-5676 before you take action. We will happy to assist you.
Note: If you were not eligible at the time of service, and/or the service was not a covered benefit of your health plan, a doctor may have the right to bill you.
When you may be contacted
During the claims adjudication process, your eligibility, co-pay, and benefits are incorporated. Some circumstances require obtaining additional information from the member in order to appropriately process the claim(s) from Providers, identify the primary payor, or to determine if a third party needs to be involved.
For example, a member may be contacted for third party liability (TPL) information if their injuries were a direct result of a car accident.
Denial Letters / EOBs
If you are an HMO or PPO member and a claim is denied, then:
HMO members will receive a “denial letter” after the claim is processed.
PPO members may receive an EOB (Explanation of Benefits) which details the amount(s) paid, and the amount you are responsible for.