Understanding insurer responses

When you submit a claim, you can receive one of three responses from the insurer. Here are our recommendations for each type of response:

• An “Explanation of Benefits” means the claim was processed.
  • It provides the response to your claim (accepted or rejected), and the amount that will be paid by the insurer.
  • Based on the amount that will be paid and who the payment recipient is, you will know what outstanding amount is owed by your client.
• If the insurance company has received the claim request but is unable to process it, a Claim Acknowledgement is generated.
  • When you receive an acknowledgement or “Claim pending” response, we recommend you void the claim, collect the full amount owed from your client and either provide them with a receipt so they can submit the claim themselves or resubmit the claim and select “Payable to: patient” to avoid any payment follow-ups on your end.
• Error means that either the eClaims system or the insurer’s adjudication engine is not functioning properly at the time you submitted.
  • When you receive an error message, we recommend you collect the full amount owed from your client and provide them with a receipt so they can submit the claim themselves.

We recommend you save a copy of the insurer’s response right away as it is only available on the day the request was submitted.