The cheapest claim dispute is the one answered before the appointment.
Most coverage surprises were predictable a week earlier: the lab was out of network, the scan needed approval, the drug moved tiers. We give employees a straight answer about what is covered before a question becomes a claim, or a claim becomes a dispute.
“Is it covered?” is really four questions.
A service can be a covered benefit and still produce a large bill. We answer the whole question, because the part employees forget to ask is usually the part that costs them.
Is the Service a Benefit?
We check the plan document, not a summary chart, because exclusions and limits live in the full document and the chart leaves them out.
Is Everyone In Network?
An in-network surgeon at an in-network hospital can still involve an anesthesiologist, lab or imaging center that is not. We tell employees which questions to ask the provider’s office, so the network check covers the whole visit.
Does It Need Approval?
Prior authorization is where covered care most often turns into a denied claim. We confirm whether it applies and who is responsible for requesting it, then check that it was actually obtained.
What Will It Cost?
Where the employee is against the deductible and out-of-pocket maximum changes the answer more than the copay does. We walk through the math so the bill is not the first time they see it.
A carrier call center answers the question asked. We answer the one that should have been.
Employees ask narrow questions and get accurate but incomplete answers. The gap between the two is where most coverage disputes begin.
Prescriptions
A drug can be covered and still require step therapy, a quantity limit or a specialty pharmacy. We check the formulary and the rules attached to it, so the first fill does not stall at the counter.
Two Plans in One Family
When a spouse has other coverage, coordination of benefits decides which plan pays first. Getting it wrong holds up claims for months, so we sort out primary and secondary before the claims arrive.
Mid-Year Changes
A new baby, a move or a job change for a spouse can change what is covered and whether enrollment can change at all. We explain the window before it closes, because a missed deadline usually waits until next open enrollment.
Employees reach a person who already knows their plan.
We work in service teams of five, so the people answering an employee’s question also know the employer’s plan, carriers and history. That context is what turns a policy answer into a useful one.
Direct Access
Employees contact us directly rather than routing through HR, which keeps personal health questions private and keeps HR out of the middle of every call.
Answers in Writing
When an answer matters, we confirm it in writing with the source, because a carrier representative’s verbal assurance is hard to rely on later.
After Hours
Outside business hours, employees can leave a question in the chat on our site, and we pick it up the next business day.
What employees and HR ask about coverage support.
Can you guarantee a claim will be paid?
No one can. The claims administrator decides under the plan document. What we can do is remove the preventable reasons for denial, which are most of them.
Which document is the final word?
The plan document and summary plan description govern. Enrollment guides and benefit summaries are useful but abridged, which is why we answer from the governing document.
Does HR hear about these calls?
Not the personal details. We report recurring themes so HR can improve communication, without passing along anyone’s health information.
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.
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