What is an employer-sponsored, or self-funded, plan?

Note: The below information refers only to a ClaimLinx Simple Option Solution plan. There are other types of self-funded plans that these details would not apply to. 

As our members know, the ClaimLinx SOS plan uses a different type of strategy for providing the health insurance benefits employees need. It combines two types of insurance coverage: a traditional insurance plan with a major carrier for primary coverage and a self-funded Medical Expense Reimbursement Plan (MERP) for secondary coverage.

See how these two levels of coverage work together so an employer can provide better benefits at a lower cost. But what exactly is a self-funded plan and how does it make benefits less expensive for the company?

A self-funded plan, also referred to as an employer-sponsored plan, is one in which a company pays directly for medical services.

In the case of a ClaimLinx SOS plan, an employer pays only for qualifying services according to a MERP determined at the beginning of the plan. Following its effective date, all medical claims are processed by ClaimLinx as a third party administrator and are paid with funds directly from the company.

Using an employer-sponsored plan allows companies to continue to provide benefits at a lower cost because they are no longer prepaying for services to an insurance company in the form of premiums. Insurance carriers charge for a plan under the assumption that every employee will be using large amounts of services. In most cases, that just is not true.

Instead employers can purchase a high deductible plan and pair that with a MERP. That way they are only paying for services actually rendered to employees.

In addition, because ClaimLinx provides a full customized schedule of benefits with a member ID card, members should not be required to pay up front for services and wait for a reimbursement (excepting special circumstances). Claims are processed and payment is sent at a later date directly to providers. This means members should experience the same conveniences as with a traditional insurance plan.

In its simplest terms employer-sponsored, or self-funded, plans are those in which qualifying medical services are paid by the company.

All of this is made possible using a 60-year-old tax code that allows companies to deduct medical expenses for its employees. What it means for employees, though is that their employer can provide the benefits they need at a cost the business can afford.

 

How to file a medical claim

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:

  1. Major medical insurance company ID card as primary coverage
    • Example: Anthem, Humana, Harvard Pilgrim, Cigna, National General, etc.
  2. 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.

  1. 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.).
  2. 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.
  3. 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.
  4. 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 is the difference between primary and secondary coverage?

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.

How a claim is processed

See below the steps a claim goes through as it is processed. Claims are processed within 10-15 business days of their receipt at ClaimLinx. Members can view their Explanation of Benefits (EOB) once it has been processed through the member portal.

Once the claim has been processed and coverage has been determined, additional steps are taken before payment is sent to the provider (detailed below). If you have any questions about the process or a specific claim, contact our team at help@claimlinx.com.

How a claim is processed copy

ClaimLinx Individual Marketplace Available For Open Enrollment

ClaimLinx is pleased to announce to all of its clients that we have added a resource for individuals looking for coverage on the insurance market – www.ClaimLinxMarketplace.com.

This site is a one-stop shop for those looking to purchase an individual plan for themselves to:

  • See off-exchange insurance plans, which can have broader hospital and physicians networks and additional benefit options.
  • Easily compare pricing and plan options available through the individual market and through the federal exchange.
  • Speak to an insurance agent to complete the application process and discuss options.
  • Find additional insurance coverage such as vision, supplemental and life insurance.

Please feel free to share this resource with any friends or family looking for individual coverage during this year’s open enrollment period. Just tell them to go to www.ClaimLinxMarketplace.com to get started.

As a member or administrator for a ClaimLinx plan, you will continue to receive the personalized service and/or benefits through the employer-sponsored plan. This is an additional resource for those who do not receive coverage through an employer.