ClaimLinx - ClaimLinx

How to file a medical claim

by ClaimLinxApril 20, 2018June 28, 20184 Comments

Note: The below information is also listed in our member packets. Download your member packet now for more information like it about your plan.

The first step for filing a medical claim for a ClaimLinx SOS Solution Plan is to show two ID cards when you visit your medical provider:

Major medical insurance company ID card as primary coverage
- Example: Anthem, Humana, Harvard Pilgrim, Cigna, National General, etc.
ClaimLinx employer funded ID card as secondary coverage

Most providers will file claims with secondary coverage. However, if the provider does not file secondary or if you receive information at your home, send any of the following items by mail or email to help@claimlinx.com to assist us in processing your claim.

Major medical carrier Explanation of benefits (EOB)
- This document is usually received about a month after a visit with a provider and has the discounted bill amount. It will come from your primary insurance coverage company (Anthem, Humana, Harvard Pilgrim, Nation General, etc.).
Documentation with diagnostic coding
- Sent by the provider, diagnostic coding explains the services performed or any diagnostic informaiton. You can also ask for this when you leave your provider’s facility.
Information about the provider
- Especially important information is the phone number to reach the physical address and billing office. You may write this on any information you send or fill out a Provider Information Form.
Invoices (not statements)
- Invoices have detailed billing information, your account number, claimant name and diagnostics. Statements do not provide any additional information for processing.

Claims are processed within 10-15 business days. You can see the full process a claim goes through once it is received at ClaimLinx. You may download an explanation of benefits for your claim once it has been processed on the member portal.

Please note that if ClaimLinx is missing any information or is waiting on requested documents, a claim will take longer to process.

If you paid up front for any services you can request a reimbursement for the services. First, you must fill out the medical expense reimbursement claim form. Then send this form with a receipt indicating you paid for the services. This can include a credit card statement, receipt from a doctor’s office, pharmacy receipt, processed beck front and back or any other proof of payment. No services can be reimbursed without this information.

What are copays, deductibles and coinsurance?

by ClaimLinxApril 10, 2018June 28, 2018Leave a comment

It’s not always clear exactly what your health insurance plan covers when fees and ending costs can feel like they’re hidden behind complex industry terms. So tackling understanding what they mean is important to knowing and using your benefits.

The below terms are all forms of “cost-sharing,” which is when medical services are paid by both the member and the health plan.

Copay — A fixed amount a person pays for qualifying types of services, such as office visits, specialist visits, prescription drugs or other procedures. For example, a member may have a $25 copay for an office visit with a primary care physician and a $40 copay for a specialist. All copays are fixed and detailed in the summary of benefits at the beginning of the plan and can be charged before and/or after a person has reached his or her deductible.

Deductible — The amount you pay for covered services before the insurance company begins to pay. For example, if you have a $2,000 deductible you will pay 100 percent of all eligible expenses until all the bills total $2,000. Once the deductible is paid, you will owe only any copays or remaining coinsurance for covered services. See Also: an article on embedded vs non-embedded deductibles.

Coinsurance — Paid after a person has met his or her deductible, it is a percentage of the allowed amount for services. For example, you have a coinsurance of 20% and the allowed amount for lab work is $100. If you have paid your deductible, you will owe 20% of the allowed amount of $100, or $20. If you have not paid your deductible, you owe the full amount of $100. Not all plans have coinsurance.

It’s important to be sure you understand your benefits when you receive your plan documents. All health insurance plans come with a summary of benefits, which includes informations on all copays, deductible and/or coinsurance. If you have additional questions about your plan, it’s best to contact the health insurance company directly.

You may always find contact information on your member ID card.

What is the difference between primary and secondary coverage?

by ClaimLinxApril 5, 2018June 28, 20182 Comments

Note: The below information refers only to a ClaimLinx Simple Option Solution plan. There are other types of secondary coverage that are similar, but can vary in detail.

The key to a ClaimLinx SOS plan is the combination of both primary and secondary coverage. It makes the plan more affordable for a business without sacrificing benefits, such as raising deductibles or copays.

In order to use these benefits, it’s important to understand the difference between primary and secondary coverage.

Primary Coverage — Also referred to as your Primary Carrier, this is the coverage from a major medical insurance company. Examples are Anthem, Humana, Cigna, Blue Cross Blue Shield, National General, Harvard Pilgrim and many more.

Members should refer to the primary carrier for their provider network and any coverage limitations. Issues with pre-authorization or required referrals all must be dealt with the primary insurance carrier.

Essentially, the primary coverage is the initial gatekeeper; all services must be approved and/or covered as a part of this plan before a member can receive any additional benefits from their secondary coverage.

Secondary Coverage — The Medical Expense Reimbursement Plan set up for the company that includes additional benefits (copays and/or lower deductible). This plan is self-funded by the company, but is administered by ClaimLinx.

This means claims are processed first by the primary carrier and then are processed by ClaimLinx for any additional benefit. Click here to see the full process. Claims are processed within 10-15 business days of their receipt, though any missing or pending information can cause delays.

Members can view an Explanation of Benefits (EOB) for their claim on the member portal once the claim has been processed.

For secondary coverage, ClaimLinx follows all coverage or network decisions made by the primary carrier. For example, if a service is denied by the primary carrier, it will also be denied for secondary coverage with ClaimLinx. The same is true for if a provider is billed as in-network or out-of-network.

That is why we encourage all of our members to verify with their primary carrier that a service or procedure is covered before going to the provider.

Click here to see how to file a medical claim if your provider is not familiar with filing for secondary coverage. Contact the claims department with questions about the process or a specific claim at help@claimlinx.com.

ClaimLinx office closed on March 30

by ClaimLinxMarch 29, 2018April 17, 2018Leave a comment

The ClaimLinx office is closed on Friday, March 30 to celebrate the holiday with family and friends. We appreciate our clients and partners’ understanding of this time for rest and relaxation for our team.

Please plan any inquiries or need for assistance accordingly. All phone calls and emails will be returned upon our return on Monday, April 2. If you have any issues or questions, please feel free to contact us and a team member will get back as soon as possible.

We’re wishing all of our clients a very happy and rejuvenating weekend!

What is the difference between an embedded and non-embedded deductible?

by ClaimLinxMarch 20, 2018January 20, 20222 Comments

A deductible is the amount of money that must be paid for covered services before the health insurance company begins paying for expenses. There are two types of deductibles, but the difference matters only for plans covering more than one individual.

The difference has to do with the amount an individual or a “family” must reach before the insurance company begins paying for expenses. Note: in this case a family can apply to a member and spouse, member and children or member, spouse and children.

Embedded Deductible — Each family member has an individual deductible in addition to the overall family deductible. Meaning if an individual in the family reaches his or her deductible before the family deductible is reached, his or her services will be paid by the insurance company.

Non-Embedded Deductible — There is no individual deductible. So the overall family deductible must be reached, either by an individual or by the family, in order for the insurance company to pay for services.

In the past, non-embedded deductibles have been an issue especially for small families, such as a member and spouse because they have fewer people to reach the high deductible.

With the passage of the Affordable Care Act, there were changes to the standards regarding out of pocket maximums that affected how insurance companies structure plan deductibles. All ACA compliant plans must have embedded out of pocket maximums. As a result, most ACA compliant plans now have embedded deductibles.

Also as a part of the law, all family deductibles must be no more than double the individual deductible rate. For example, if the individual deductible is $3,000, the family deductible can be no more than $6,000. Both of these measures were an effort to alleviate the financial stress on smaller families.

However, these rules do not apply to the self-funded Medical Expense Reimbursement Plans ClaimLinx clients use for their benefits, so it is possible our members still have a non-embedded or higher family deductible. Always refer to your summary of benefits for more information regarding your own deductible.

To learn more about how ClaimLinx consultants guide small business owners to better, less expensive insurance plans, contact sales@claimlinx.com.

Talk to our team about how you and your employees could be saving thousands on health care each year.