Maximum out-of-pocket claims

How your MOOP works

The maximum out-of-pocket (MOOP) amount represents the most you will pay for covered health care services annually. It includes your deductible, eligible copays, and eligible coinsurance payments, excluding monthly premiums.

Most payments after receiving care count towards your MOOP. Once you hit your MOOP limit, your plan pays 100% of your covered benefits until the MOOP resets to zero in the next coverage year.

Reading your MOOP claim listing

The claim listing, also called an audit report, outlines the services you received and their contribution to your MOOP amount. Use it to keep an accurate record of how much your providers have charged towards your MOOP amount.

Your listing may not show recent out-of-pocket payments

Due to the time required to process claims, your most recent cost shares may not appear in your MOOP claim listing immediately. Under California law AB1455, contracted providers are allowed up to 90 days to submit a claim. After submission, the responsible entity has 45 business days to either pay or deny the claim.

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

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 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. Member Cost Share Owed: The amount you owe for services you received. You are responsible for paying this amount. Cost share payments are made to a provider or a facility, not Sharp Health Plan. We are not able to confirm if you have paid your cost share to the provider listed. If you have any questions about the balance due, please contact your provider directly.
9. 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.
10. Claim Tier: Depending on where you accessed care, you will see different codes. A “1” means you accessed care within the Sharp Health Plan Performance or Premier Network. A “2” means you accessed care within the Aetna Open Choice PPO Network or First Health Network and a “3” means you accessed care out-of-network.
11. Comments: Offers more information about your claim.
12. Total of Cost Share Incurred: The sum of the cost share amounts. Use this number to find how close you are to meeting your MOOP amount.
13. Total of Cost Share Owed: The total amount you owe for the services you received. Cost share payments are made to a provider or facility, not Sharp Health Plan. Please contact the provider listed if you have questions.

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.