Meet the exceptional Bill Tillman, the Claims Research Specialist. He is a part of the Claims and Billing Department. With his extensive expertise and experience in the field, Bill is committed to providing members and clients with top-notch service.  

Bill cares about ensuring all claims are handled efficiently and effectively. You can trust Bill to go above and beyond to meet your needs and exceed your expectations. 

What does Bill Tillman do at ClaimLinx? 

Bill has several job responsibilities. His primary focus is researching issues and solving problems when it comes to claims processing. Some of these responsibilities include:  

• Serving as a liaison between members, providers, and primary when issues arise. 
• Filing claims for Reference-Based Pricing plans and non-contracted primary plans. 
• Researching and/or completing balance bill requests for plans without a traditional network. 
• Reconciling uncleared checks through the ClaimLinx TPA. 
• Collecting claims and EOBS for MERP processing. 

When did Bill start at Claimlinx?   

Bill has been working in the Claims and Billing Department at ClaimLinx since November 2018. 

What was your favorite member testimonial you received?  

“Hey Bill,  

Thanks for the response. I have gotten into the habit of sending everything to you because of your diligence in getting things taken care of. If I need to send things to others, please let me know.  

Thanks again!” 

What do you like to do in your free time?  

When Bill is not working at ClaimLinx, he spends time with his family. They are involved in many activities, which keeps him busy. 

How does Bill’s role help members and clients?  

The Claims Research Specialist helps bridge the gaps between members, providers, and carriers so claims can be processed accurately.  

His role focuses on helping members navigate paperwork so that the Claims Team can process claims. He also serves a role for employers, as a person that checks on uncleared funds to providers.  

Contact the Claims Research Specialist 

Reach out to Bill with questions by email at btillman@claimlinx.com or by phone at (513) 985-4468.   

How does ClaimLinx’s Claims Department help employers? 

ClaimLinx is a third-party administrator for employer-funded plans. It is part of our unique strategy for purchasing health insurance that helps businesses save money without sacrificing benefits.  

The ClaimLinx Simple Option Solution is ClaimLinx’s premier product. It’s our trailblazing solution for purchasing employer-paid benefits at a lower cost.  

It combines a high-deductible insurance plan with a self-funded medical expense reimbursement plan (MERP). It’s taking a regular health insurance plan and mixing it with a self-funded plan to get the best option for employers and workers. 

The makers of the new class of weight loss drugs Ozempic, Wegovy, and Mounjaro are working to prove their popular drugs have enough health benefits for insurance carriers to cover their high price tags.  

It could mean a big shift in costs in the future. Right now, many insurance companies do not cover these drugs or have strict conditions on coverage because of their high costs.  

It’s a struggle that has left many Americans unable to access the drugs.  

What are the new “weight loss” drugs?  

The most popular drugs on the market for weight loss are Ozempic, Wegovy, and Mounjaro. Ozempic and Mounjaro are approved by the FDA to treat type 2 diabetes. These drugs are not approved to treat obesity but are currently being prescribed for it.  Wegovy is the only version of these drugs that has been approved for chronic weight management.  

Once prescribed, patients take the drugs through subcutaneous (under the skin) injection. These drugs have become increasingly popular because of how effective they are in aiding weight loss. 

 Are these drugs covered by insurance?  

Many health insurance plans do not provide coverage for the medication Ozempic and Mounjaro when it is used for weight loss. This is because they are currently only approved by the FDA for the treatment of type 2 diabetes. Although some healthcare providers may prescribe the drugs off-label for weight management, it is unlikely that insurance companies will cover the cost of medication for this purpose. 

Insurance companies that do provide coverage for weight loss drugs often require additional documentation to see if the patient qualifies for coverage. That may include test results or assessments by physicians. Requirements for coverage from the insurance company can change at any time.  

Providers across the country have complained of changing standards that have made it more difficult for patients to keep coverage.  

How do Ozempic, Wegovy, and Mounjaro work? 

Ozempic and Wegovy both use the ingredient semaglutide. It stimulates the GLP-1 receptor, which makes people feel less hungry and slows the emptying of the stomach. Studies show that the drugs help people: 

• Lower blood sugar 
• Reduce the risk of heart failure 
• Achieve average weight loss of about 15% 
• Experience less appetite or cravings 

People using the drug also experience side effects like nausea, abdominal pain, low blood sugar, and other stomach issues.  

Mounjaro uses the ingredient tripeptide, It is a glucose-dependent insulinotropic polypeptide receptor and GLP-1 receptor agonist. In essence, it mimics the hormones the intestines naturally produce so that a person feels fuller for longer. It also slows digestion. 

People using Mounjaro often experience the same improvement and side effects as Ozempic and Wegovy. Again, Wegovy is the only one of these drugs approved by the FDA for weight management alone. Ozempic and Mounjaro are approved as drugs to treat type 2 Diabetes. 

Are these drugs covered on my ClaimLinx plan?  

All plans ClaimLinx administers are custom to the company so always check with your plan administrator if you have questions about benefits. However, as a general rule, the MERP Plans ClaimLinx administers follow the coverages outlined in the primary insurance plan.  

That means members can receive coverage for these drugs if they meet the standard the insurance company requires. That includes limits on coverage for people who do not have type 2 diabetes. 

What are the costs of these drugs? 

Ozempic, which is intended for those with type 2 diabetes, comes in pre-filled pens that hold multiple doses. If you are eligible for insurance coverage, you can get Ozempic for as little as $25 per month. However, without insurance, the average cost of Ozempic is approximately $892.06 per month. 

Mounjaro, though it has a different ingredient, carries a similar price tag without insurance. This medication is also intended for those with type 2 diabetes. It can cost up to $1,069.08 per month if it’s not covered by insurance.  

Wegovy, when it is prescribed for weight loss, is a weekly medication that works best when taken along with regular exercise and a low-calorie diet. The cost of Wegovy can be more than $1,300 per month without insurance. 

Why do insurance companies deny coverage?  

Coverage for these drugs is likely to change drastically in the coming years. Insurance companies have cracked down on coverage recently because of the high sticker price of the drugs.  

According to two surveys conducted in October 2023 by the International Foundation of Employee Benefit Plans and the employee research firm Savanta, only 25% of employers covered GLP-1 drugs for weight loss in 2023. 

High demand compounded with high cost has forced many companies and/or insurance carriers to limit coverage. Currently, insurance companies point to the fact that Ozempic and Mounjaro are only approved for type 2 diabetes as the major reason for denying coverage  

However, coverage decisions are a more complex picture and are subject to change in the future. If the drugs are proven to reduce health risks or expensive health events, coverage may change. That is why the drug makers are in a rush to prove the wider uses of the drugs.  

Spring is a time of new growth, with flowers emerging from beneath the snow, trees blooming, and dormant grass awakening. It is also an opportunity to recommit to a healthier lifestyle. 

Spring is a time for cleaning and outdoor activities, but it is also the season for allergies. These tips will help you maintain good health during spring. Although they may not guarantee complete prevention, it is always better to reduce your risk as much as possible. 

Spring cleaning is not just a practical or traditional activity. Research has shown that cleaning can help reduce stress while removing clutter and maintaining cleanliness can help reduce anxiety. Moreover, it can improve air quality, leading to better health, and the physical activity involved can help you stay active without even thinking about it. 

Get started Spring cleaning: 

It Lightens Your Mood:  

Eliminating clutter can help alleviate stress. When our home is disorganized, it can overload our senses and make us feel weighed down. By creating an orderly and organized living space, we can exert some influence over our environment. Since we cannot control many sources of stress or anxiety in our lives, simply having a more organized personal space can have a calming effect. 

Set a schedule:  

It is highly beneficial to have well-defined objectives and a structured plan when undertaking a major home project. It is recommended to create a manageable schedule according to your availability by setting aside specific days or weeks for various tasks such as decluttering and cleaning different areas, like the kitchen, garage, living spaces, bathrooms, and bedrooms. Additionally, you may want to consider other tasks as well. 

Ask for help:  

It is important to work together with your family to clean up any mess that has been made. Even young children can help with simple tasks, and this is a great chance to teach older children how to do more thorough cleaning. While they might not love the process, everyone will appreciate the result of a clean and tidy home. 

Here are tips to have a healthier spring:  

Reset Your Sleep Schedule: 

As spring approaches, it becomes increasingly important to wake up earlier. By waking up earlier, you can make the most of your day and enjoy more hours of daylight. This will allow you to have more free time to do the things you love, such as reading, exercising, or relaxing with a cup of tea. So set your alarm a bit earlier and start your day off right! 

Eat Fresh Produce:  

Eating a lot of raw fruits and vegetables can accelerate the detox process, leaving you feeling refreshed and energized. They are also packed with the vitamins and nutrients your body needs to perform at its best. 

Stay Active: 

Physical exercise offers numerous benefits for our bodies, especially during spring when it is the perfect time to start a new fitness routine. It also has a positive impact on our mood. If you have been feeling down during the winter months, adding some physical activity to your day can instantly release feel-good endorphins and boost your mood. 

Photo by AlenaKoval

The ClaimLinx office will close on Friday, March 29th for Good Friday. Staff members will be enjoying the day and getting ready to spend the Easter holiday weekend with family and friends.

Our team members will respond to any calls or messages as soon as possible upon our return on Monday, April 1st. We appreciate your patience and understanding. 

To kick off the holiday, here are some facts about Good Friday: 

• Good Friday falls on the Friday before Easter Sunday, which varies each year. It is determined by the ecclesiastical approximation of the March equinox. 
• Hot Cross Buns were traditionally baked on Good Friday to be eaten on Easter Sunday and are said to be good luck. Nowadays we eat them throughout Easter. 
• Catholics are not allowed to eat meat on Good Friday. Instead, Catholics will often eat fish, and this is where the tradition of having a ‘chippy tea’ on Good Friday. 
• Good Friday is not an official holiday in the US or around the world 

And more facts about Easter: 

• Easter can take place any day between March 20 and April 23.  
• Easter is the celebration of the resurrection of Jesus Christ in the Christian religion.  
• The Easter Bunny legend began in Germany. The Easter Bunny dates back hundreds of years, beginning in pre-Christian Germany.  
• More than 1.5 million Cadbury Creme Eggs are produced every day. The Creme Egg is the most popular egg-shaped chocolate in the world.  
• Painting eggs originated from a Ukrainian tradition.  
• The White House Easter Egg Roll event has been celebrated by the President of the United States and his families since 1878. 

 

ClaimLinx offers clients a private portal to help with the administration of the company benefits plan. Through the portal, administrators can find enrollment forms, copies of the schedule of benefits, and other plan documents.  

They can also upload documents, enrollments, terminations, and changes securely.     

Cyber-attacks are becoming increasingly common, particularly targeting small to medium-sized businesses. These attacks are often more sophisticated and targeted. According to Accenture’s Cost of Cybercrime Study, 43% of cyber-attacks are aimed at small businesses, but only 14% are prepared to defend themselves. 

The following is a list of the most common types of attacks that small businesses face: 

• Phishing/Social Engineering: 57% 
• Compromised/Stolen Devices: 33% 
• Credential Theft: 30% 

Why is it important to secure employee information? 

Since cyber-attacks are becoming more frequent, ClaimLinx offers a secure way for clients to send employee information. To secure members’ personal information, we suggest sending any personal information through the employer portal.  

What can administrators do in the system?  

The employer portal is a secure way to download and upload documents. It helps with plan administration. Through the employer portal, administrators can:  

• Submit New Enrollment paperwork.  
• Download Plan Brochures  
• Submit employee Termination paperwork.  
• Send Changes of Address forms  
• Submit Plan Change documents.  
• Download Schedule(s) of Benefit  
• Review contract details.  
• See updates from ClaimLinx  
• and more!  

Employer Portal Improves Service 

The system also allows for more collaboration between our team and administrators. You can ask questions about documents within the portal. You may also see who to contact regarding questions. The system includes features we are sure employees will find useful.  

We encourage administrators to use this portal as a way to ensure they are always using the most up-to-date forms for new employee enrollment. Remember, using out-of-date forms can slow the enrollment process.  

How to access the Employer Portal  

All administrators receive an invitation to access directly to their email. You can also access your account at any time by going to https://claimlinx.clinked.com/.   

Contact service@claimlinx.com if you have not received an invitation or if you are having trouble accessing your company’s account.   

Who has access to the Employer Portal?  

Please be advised this is a service provided only to clients. The portal is not intended for individual members and employees.  

We are constantly looking for more ways to improve our services for administrators, so if there is a document or resource you would like to see added to the employer portal, please let us know.  

What do administrators like about using the portal?  

• Notifications are automatically sent to ClaimLinx when documents, such as enrollments and terminations, are uploaded.  
• More than one administrator can have access to the portal.  
• Comment and/or ask questions directly on documents.  
• A custom home page with your Service Team information  
• Notifications are automatically sent to you when ClaimLinx updates documents.  
• Manage your username and password on your own.  

Who to contact with questions?  

If you did not receive your email invitation to the new system or if you are having trouble navigating the page, contact service@claimlinx.com. Our team members are happy to assist.