We know that filing a claim can be stressful for your clients. They may still be dealing with an ailment or unsure about the status of their finances.
That’s why we strive to make our claims process as straightforward and efficient as possible. We aim to resolve claims quickly while keeping our members up to date on their claim status during each stage of the process.
We offer a large claims team and global customer support to ensure we cater to our customers’ needs and exceed their expectations. We are continually:
Read on to learn about our claims process timeline and discover helpful resources you can use to answer your clients’ burning questions.
Once we receive a new claim from a provider, we will pay, pend, or deny the claim within 30 days.
NOTE: Each U.S. state has its own required claim turnaround time that begins when we first receive a claim from a provider. The number of days we are allowed to either pay or deny the claim may vary depending on whether we require additional information to complete the claim. This time frame may also be suspended until we have received the last piece of requested information.
Payment and an Explanation of Benefits will be mailed to the provider and/or member. The Explanation of Benefits will detail how the claim was paid, including any in-network discounts, deductibles, and co-insurance.
In most cases, we will request a Claimant’s Statement and Authorization form upon receipt of a claim from a provider.
The member has 45 days to return the completed and signed form. We will close claims due to a lack of information if the member does not return the form to us within 45 days of our initial request. Encourage your clients to respond quickly as to not stall the claims process.
If we need additional information to approve or deny the claim, we will request it from the relevant medical provider(s). We may request medical records from a hospital, primary care physician, emergency room reports, outpatient reports, or other relevant documents.
Providers have 45 days to return the requested medical records to us. Note that we will close claims due to a lack of information if the providers fail to meet this deadline.
Once we have received the requested medical records, our claims examiners will review them to determine whether to approve or deny the claim.
We will finalize most claims at this point. However, there are rare cases when we will need additional information.
Denials are the result of an exclusion or the date of medical treatment falling outside the member’s coverage period.
See A Guide to Claims for Producers in Producer Zone to learn the step-by-step process your clients must take to file a claim inside or outside the United States.
Members must complete, sign, and submit a Claimant’s Statement and Authorization form for each incident. We offer two convenient options for submitting the form so your client can choose the method that works best for them:
If your client chooses the mail-in option, they may download and print the form via Client Zone or the Claims Resource Center. They may also request that we fax, email, or mail them the form.
If your clients have questions or concerns about the claims process, direct them to our Claims Resource Center. They’ll find frequently-asked questions, glossary terms, and contact information so they can reach out to us with any questions.
Members will also find two helpful videos that break down the claims process into easy-to-understand steps:
Client Zone is your clients’ convenient policy management portal. Within Client Zone, members can easily:
Once you get contracted and gain access to Producer Zone, be sure to read through our Guide to Claims for Producers to learn the specific ins and outs of filing a claim and see a step-by-step Client Zone walkthrough.