Claim accepted
This type of response is generated when the insurance company has fully adjudicated (or processed) the payment request.
If the payable was changed, the following message is displayed before the response.
Following is an example of a claim accepted message wherein the payment will be made to the Clinic/Organization.
If the Total Payable to was changed from Clinic/Organization to Insured Member, the following message is displayed. Please note that you must collect the full claim amount from the patient.
From the Insurer response (PDF) section, you can view or save the Explanation of Benefits, or email it to the patient. An Explanation of Benefits (EOB) is a response generated by the insurer when it has fully adjudicated or processed the payment request. This statement provides the actual results of the adjudication, including what amounts, if any, will be paid by the insurance company.
If Total Payable to was set to Clinic/Organization, the Payee Name is the name of the clinic/organization, and the Payee Address is their address.
The following table describes some of the fields on the Explanation of Benefits.
|
Field |
Description |
|---|---|
|
Submitted |
The total amount originally submitted for the claim line. If this is empty, the claim line was added by the insurance company. There should be a note explaining why a line was added. |
|
Eligible |
The amount that the insurance company deemed eligible when calculating the amount paid for the claim line. |
|
Payable At |
If applicable, the percentage that is covered by the patient’s policy for the claim line. |
|
Totals |
The Submitted Amount, Eligible Amount and Deductible columns have a total indicated. |
|
Note(s) |
The insurance company’s notes relevant to the claim lines or to the claim in general. There is generally a note providing how to contact the insurance company. |
If your patient or your patient’s parent/guardian notices an error in the response (such as an incorrect date of birth), they must contact their insurance company directly to have the error(s) corrected.
