Your people call us, not the carrier.
This is the part of the job employees actually see. A denial arrives, or a bill arrives that does not match what anyone was told, and somebody has to sit on hold with a claims department and argue a point of fact. When that somebody is your HR manager, the cost of the benefits program quietly includes their week.
Most denials are not coverage decisions. They are data problems wearing a coverage decision’s clothes.
A denial letter reads as final. Read the codes underneath it and a large share of them turn out to be something that can be corrected rather than argued, which is why the first step is always to find out what actually happened rather than to appeal immediately.
Coding and billing errors
A wrong procedure or diagnosis code, a missing modifier, a facility billing a service the carrier expected from a professional claim. Nothing about the coverage is in dispute — the claim simply does not describe what happened.
Eligibility mismatches
The carrier believes the employee or a dependent was not covered on the date of service, usually because an enrollment or termination file disagreed with payroll. This is the single most common denial we see, and it is fixed upstream rather than appealed.
Medical necessity and network
The genuine coverage disputes: a service the plan considers not medically necessary, a prior authorization that was never obtained, or an out-of-network provider inside an in-network facility. These are the ones that need a real appeal, with the plan document and the clinical record attached.
We take the file, not the phone number.
Forwarding an employee to the number on the back of the card is not advocacy. Your account manager and customer service seat take the case, find out what the claim actually says, and pursue it — with the employee told what is happening rather than left to guess.
We read the record first
Explanation of benefits, the provider bill and the plan language, side by side. An appeal written without all three is an opinion, and carriers answer opinions with form letters.
Appeals, then the next level
Internal appeal with the clinical documentation attached, and where the plan and the law provide for it, independent external review after that. A first denial is a position, not a verdict.
Balance bills
Federal surprise-billing protections changed what a provider may bill a member for emergency care and for out-of-network care delivered at an in-network facility. A bill that ignores those protections is challenged rather than paid.
Employees ask benefits questions at inconvenient hours.
Around the clock
Our chat access answers coverage questions at any hour and escalates to a person when it should. Most questions are not disputes — they are someone checking whether a visit is covered before they go, which is the cheapest moment to answer.
Off your HR desk
Employees contact us directly. Your HR team stops being the translation layer between a distressed employee and a claims department, and gets the week back.
Reporting you can use
Claims, pharmacy and stop-loss data pulled into one report instead of three carrier logins, with high-cost outliers flagged before the renewal conversation rather than during it.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
Bloomfield Hills, MI 48304
248.370.8853
719.425.2649
281.404.5670
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