Explanation of Benefits (detail)

You are likely reading this article because a recent claim was denied with the following message or something similar to it:

311- Anytime there is insurance we require their Detailed Explanation of Benefits. This document is what your other insurance carrier provides you . It shows the insurance company name, Patient name, Treatment or Service details including the date, Full cost of the treatment, the amount they paid toward the expense (even if it is 0) and their applicable messaging explaining why they paid or did not pay.

Contact your insurance carrier directly to find out how to obtain your copies. Please note, online printout copies are acceptable.

Here's what it means:

National HealthClaim is not insurance. Instead, we provide you with a spending account that pays for your expenses once you have used all your Group plan insurance coverage(s).

Note: This can include a spousal insurance plan. You must submit to all other plans first before submitting to us for remaining unpaid portions.

Now because insurance was involved with the expenses you are trying to claim with us (even if they paid 0) - we need you to send us their 'Explanation of Benefits.'

Where can I find the Explanation of Benefits from my insurance carrier?

 Sometimes they automatically email it to you. Other times you would receive them by mail.

However, we recommend simply looking to see if you have an online account with your insurance carrier. You can often view/print this document directly from there.

Note: We need a detailed explanation of benefits, summary documents are not acceptable. It should include the following information: 

• The insurance company name
• Provider information.
• Patient/Claimant information.
• Treatment or service details, including the date.
• The full cost of the treatment or service.
• The amount paid by the insurance company.
• Messaging that explains why the insurance company paid or didn't pay.

Of course, if you are having any difficulty getting this document, contact your insurance carrier directly to get it. Then you can send it to us by resubmitting your claim. 

Note: If you do not have coverage, you are not required to submit it to your insurance simply to get a rejection. Instead write a quick disclaimer on the original invoice you submit to us, stating the reason you did not submit the expense to insurance (e.g no vision coverage, or insurance maximum already reached).