Claims FAQ

Claim

 

A request by an individual (or their provider) for the insurance company to pay for services obtained.

While it is standard for most providers to submit a claim for the patient or member, it is also possible for the member to submit the claim themselves. On the member ID card, there will be a list of claims addresses for medical and, if applicable, dental and vision:

Medical claims will almost always be sent to the network's address first. The network for a specific plan is indicated on the member ID card (see the Network page for more information). For dental, vision, and select medical claims, they will be sent directly to the CareFactor address. As shown above, this information is detailed on the member ID card. When submitting a claim as a member, a copy of a full bill of service (one which includes the patient's name, the date of service, and a list of services with their charges) with a copy of the member ID card is needed to be sent to the appropriate address.

Claim Appeal

A member may appeal a non-covered claim or service on a claim. A participant has 180 days to file an appeal to an adverse benefits determination. A section of the plan document will describe the claim appeal procedure and the timeliness required for the administrator’s response.

Coinsurance

The portion of covered expenses that is shared by the plan and the covered person after the deductible is satisfied.

Coordination of Benefits (COB)

A provision intended to prevent the payment of benefits which exceed total allowable expenses. It applies when a member or any eligible dependent who is covered by the plan is also covered by any other plan or plans. When more than one coverage exists, one plan normally pays its benefits in full and the other plans pay a reduced benefit. In order to check for any new insurance information, companies are required to request information updates, which is detailed further on this page below under Other Insurance Verification.

Copayment

A fee charged to members to offset costs for each office visit or pharmacy prescription filled. In most cases, the copay is separate and unaffected by the deductible. For example, if you have a copay for office visits, the copay will be all the member is charged for the visit regardless of whether your deductible has been met. There are a few exceptions in which you may see an amount owed other than the copay:

  • The service or a portion of the services on a claim are not covered by the plan

  • A service on the claim other than the office visit is not applicable to be billed in conjunction with the office visit. These services will typically fall under deductible and/or coinsurance

  • The plan states the member must meet the deductible in addition to a copayment being owed before the insurance pays on a claim (this is typically only seen with out of network benefits on certain plans).

Deductible

A set dollar amount that a person must pay before insurance coverage for medical expenses can begin. They are typically charged on an annual basis - either per plan year or calendar year, depending on the insurance plan.

Explanation of Benefits (EOB)

A form that is mailed to members and providers to explain the details of a processed claim. An EOB will show the amount paid by the insurance, the amount that is the patient/member's responsibility, amounts written off per a network's contract, codes and explanations of denied services, steps needed to be taken to correct denial codes, and other relevant information.

Form: Accident Claim Information

Some claims, particularly emergency room and some hospital visits, may indicate an injury was a reason for the visit. Unfortunately, claims do not contain information on the nature of the injury or the particular cause of the nature of the visit. If a claim's details suggest there may be an injury or accident involved, a request will be sent to the member for accident information. This request will be located on the EOB for the claim in question. It will show the claim as denied and the full charge as the member's responsibility until the form is filled and returned to the insurance company. 

 

This form must be completed within a specific time period from the date of denial. If the form is not completed within that period, then the claim may be denied.

 

While the Accident Claim form is not included with the EOB, you can find it:

  • on the member's CareFactor account under the Forms menu

  • by calling CareFactor and request the form be sent to via mail, email, or fax

Form: Other Insurance Verification

Every twelve months, a form will need to be filled out in order to update a member's account on whether they have any other insurance coverage. This typically only applies to dependents; cardholders (the primary member/employee on the account) are only asked for this update under special circumstances. 

 

If any claims are denying because the update is overdue, this form must be completed within a specific time period from the date of denial. If the form is not completed within that period, then the claim may be denied.

 

While the Other Insurance Verification form is not included with the EOB, you can find it:

  • on the member's CareFactor account under the Forms menu

  • by calling CareFactor and have the form sent to them through mail, email, or fax

In Network and Out of Network

In network typically refers to physicians, hospitals or other health care providers who contract with a network (usually an HMO or PPO) to provide services. Out of network typically refers to physicians, hospitals or other health care providers who do not contract with a network to provide services. Depending on the insurance plan, expenses incurred for services provided by out of network providers might not be covered, or coverage may be less than for in network providers. 

Out-of-Pocket Maximum

The maximum dollar amount a covered person will pay for covered expenses in any benefit period, unless otherwise specified in the Schedule of Benefits.

Personal Health Information (PHI)

Information covered by the HIPAA Privacy Rule, including all medical records and individually identifiable health information used or disclosed by a covered entity in any form, whether electronically, written, or orally.

Pre-certification

A provision that requires the claimant or provider to contact a toll free phone number upon learning of the need for a hospital admission , within a specified period following an emergency admission, or for other conditions and procedures specified by the plan. Failure to comply with the pre-certification requirement may result in a penalty (e.g., a flat dollar amount or eligible expenses paid at a lower coinsurance rate). The purpose of a pre-certification requirement is to review the proposed confinement for appropriateness, medical necessity, and to identify case management opportunities as soon as possible.

Timely Filing

A period of time health plans designate (usually one year), beginning with the date charges are incurred, in which the claim must be filed.