So, you’ve filed a claim—but then what? Where does it go and what happens next?  Insurance companies don’t always share what happens behind the scenes, so in the spirit of transparency we're re-sharing this information for anyone that needs a refresher. Below, we walk you through each step at how the average claim gets processed.

Phase 1: Establish our relationship with the provider

First, the insurance company asks:

  1. Is this provider in our system?
    a. Some providers are in our system even if they’re not contracted us.
  2. Is this provider contracted with us?
  3. Is prior authorization required per contract?
  4. Does the contract allow for payment of the service?
a. If yes, what’s the rate of this service?
The answers to these four questions determine either the allowed amount or a contractual denial.

Phase 2: Issue payment & explanation

Next, the insurance company prepares an electronic remittance that includes:

• what we’re paying (we pay providers weekly)
• what the member owes
• what’s being denied and why

We use the CARC and RARC for denial codes to ensure everything is clear to the provider—

Phase 3: Questions and appeals

Then, if a provider has questions, they can use the self-service tools in our portal or call/chat with customer service. That way we can disclose our appeals process, so providers understand denials.

We encourage to visit our policies & guidelines page with links to information that will help you find out which services, treatments, and drugs are covered under our plans.

To learn about claims processing from the member point of view, view the infographic.

Topics: Claims, claims processing


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