1. Understanding the Claims Process
Approval date: 07/29/2015
Code:
Revised: 07/29/2015
Understanding the Claims Process
Last updated July 29, 2015
©2012 SureBridge | Proprietary and Confidential.

2. The Claims Process is Fun and Educational
This presentation will walk you through the following:
Submitting a claim
What does one use to submit a claim?
Getting claim status
What is payable?
What s or correspondence does one receive?
Dealing with a claim investigation
Example reasons for investigation
What s or correspondence will one receive?
©2012 SureBridge | Proprietary and Confidential.

3. ©2012 SureBridge | Proprietary and Confidential.
Claim Submission
Common questions
What form does one use?
Where can one find it (agent, insured)?
What other things should one include?
Process
Submit via fax
Via secure portal
Why not (HIPAA)?
What next?
TAT for an average claim
©2012 SureBridge | Proprietary and Confidential.

4. ©2012 SureBridge | Proprietary and Confidential.
Example Claim Form
The Claim Form can be found on the printed welcome packet, on the broker portal, and on the member portal. You can also call customer service to request a claim form.
Broker Portal:
Under the SureBridge Tab, on the Resource Center, click on Carriers, select SureBridge, and then click on the company link under Websites for Agents to access the claim form. You will need your sign in for the company website.
See next page for Member Portal information.
©2012 SureBridge | Proprietary and Confidential.

5. Submitting a Claim on the Member Portal
Members can click on the quick link on the member portal at to access their claim form.
Members can even submit basic claim information from the Claim Center link. However, any signed forms or documentation must still be submitted via fax or uploaded as attachments using the Express Request function on the Website.
©2012 SureBridge | Proprietary and Confidential.

6. Important Information for the Claim Form
How long does it take to receive Supplemental insurance benefits after a claim is filed?
The average processing time is 5-7 days once all required information has been received on a claim that does not require an investigation or additional research.
Why do some claims take longer than the average time to process?
Due to policy provisions including pre-existing, first occurrence, qualifying event definitions, and exclusions and limitations, additional information may be requested on the Insured’s behalf to determine the eligibility of the supplemental insurance benefits.
Why does a customer have to complete another authorization when they have completed the one in the claim form packet?
There are some providers (physicians and hospitals) that require their patients to complete a special authorization form specific to that provider and the information being requested.
Where does one submit a claim?
Mail: P.O. Box
North Richland Hills, TX
FAX:
Member Website
See previous slide
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7. ©2012 SureBridge | Proprietary and Confidential.
What should I include?
Claim submissions should include everything asked for in the claim form. This can include, depending on claim type:
Signed Claims Authorization for Release of Information Form
Physician’s Statement
Medical Records (test results that determined the diagnosis are preferred)
For greater detail, see the handout entitled
Claim Submission Table (link to the right).
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8. ©2012 SureBridge | Proprietary and Confidential.
Claim Status
Where does one go for status?
Member portal
Phone Call
What letters might a customer receive?
A letter requesting additional information is not uncommon
Be sure to include everything asked for in the claim form to avoid delays
©2012 SureBridge | Proprietary and Confidential.

9. Using the Member Portal for Claims Information
Customers and agents can access claim information either by calling customer service at :
Customer Support – , Monday through Friday 8:00am to 5:00 pm
Producer Support – , Monday through Friday 8:00am to 5:00 pm
A customer may also go to the Member Portal, clicking on Claims Center and selecting a claim. Please note the Member Portal only contains finalized claims.
HIPAA HIPAA
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10. Critical Illness Direct Claims Example
Jenny Heart, at age 45 was diagnosed with Stage IV Breast Cancer. Although Jenny had been going for her annual mammograms and one had required additional review by a pathologist, this was her first diagnosis of internal cancer. As a result, a surgery was performed and she was treated with chemotherapy and radiation. Luckily for Jenny, she has an Option 4 Critical Illness Direct plan to supplement her Bronze EHB health insurance.
BILL
After PPO Discounts
Outpatient
Surgery Facility
Surgery
Chemotherapy
Radiation
$3,000
$2,500
$8,000
$6,000
Paid By Health Plan $0
$8,000
$6,000
Out Of Pocket
$3,000
$2,500 $0
The Bronze EHB plan only paid $14,150, leaving Jenny OOP $6,350 in medical expenses. SureBridge paid Jenny $30,000 covering the gap left by the EHB plan and giving Jenny $23,650 to help with her lost wages and other incidental expenses such as her mortgage and car payment.
Paid By SureBridge Plan
Anesthesia
$1,000
$ 150
$850
$6,350
$30,000
TOTALS
$14,150
$6,350

11. Accident Direct Claims Example
Jenny Heart, age 43, had a car accident. Jenny is knocked unconscious, fractures her skull, breaks multiple ribs and both legs. Jenny is flown by Care Flight to the nearest Emergency Room where she is immediately admitted for surgery and spends a total of 7 days in an ICU room and another 15 days in the hospital. Luckily, in addition to her bronze level EHB health insurance, Jenny has a Level 4 Accident Direct plan.
BILL
After PPO Discounts
Emergency
Room
Hospital Room
(15 Days)
$1,000
$5,000
$10,000
Paid By Health Plan $0
$6,650
Out of Pocket
$1,000
$2,000
$3,350
The Bronze EHB plan only paid $6,650, leaving Jenny OOP $6,350. SureBridge paid Jenny $25,000, covering the gap left by the EHB plan and giving Jenny money to help with her lost wages.
Paid By SureBridge Plan
ICU Room
(7 Days)
$6,350
$25,000

12. Hospital Confinement Direct Claims Example
Jenny Heart, age 43, had a car accident. Jenny fractures her skull, suffers a concussion, and has multiple contusions. Due to the fracture in her skull, Jenny is confined in the hospital for 7 days. She spends the first and second day in an ICU room to monitor for swelling of the brain and spends the third through seventh days in a regular hospital room. Luckily, in addition to her bronze level EHB health insurance, Jenny has a Level 3 Hospital Confinement Direct plan.
Paid By SureBridge Plan
(1st - 2nd day)
$4,000
(3rd – 7th day)
BILL
After PPO Discounts
ICU
Room
(1st - 2nd Day)
Hospital Room
(3rd – 7th Day)
$6,000
$4,500
Paid By Health Plan $0
$4,150
Out of Pocket
$6,000
$350
The Bronze EHB plan only paid $4,150, leaving Jenny OOP $6,350. SureBridge paid $8,000, covering the gap left by the EHB plan and giving Jenny money to help with her lost wages.
$6,350
$8,000

13. Example Request for More Information
To the right is an example letter indicating we require more information. In most cases, the Insured is not responsible for this information.
How long does it take to process a claim when more information is needed?
The average time is 30 to 60 days from the date of the request.
Unfortunately this is up to the provider (physicians and hospitals). Some providers take 6-8 weeks to process requests for medical records.
In addition, if the doctor requires a special authorization that we have to obtain from the customer, this can delay the process as well.
©2012 SureBridge | Proprietary and Confidential.

14. What if my Information is Late?
Claim follow-up is done every 8-10 business days for claims waiting for information. If the information is not received, this letter is sent out.
If the information is not received within 30 business days*, the claim is closed for lack of information and this letter is sent.
*Can close sooner based on state-specific time of service regulations.
©2012 SureBridge | Proprietary and Confidential.

15. Example Claim Denial Letter
What if the claim is denied?
The customer will receive an EOB indicating the claim is denied.
In addition, the customer may receive a letter explaining the denial in more detail.
An example is shown on the right.
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16. Understanding Claims Investigation
Why are some claims investigated?
Claim submitted in the first 12 months
Claim indicates possible undisclosed medical condition
Possible Fraud
Extended Hospital Stays For Minor Accidents
Falsified Medical Documents & Claim Forms
Repeat Accidents
Coverage Applications For Multiple “Related” Applicants With Slight Variation
Extended Disability Periods With Little Or No Follow Up With Their Physician
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17. Repeat “Accidents” – Real & Falsified
These types of repeat “Accidents” are typically filed on our Accident or Disability Policies
In most instances there are no witnesses to the “Accident”
Many claimants have filed previous claims for other “Accidents” or Disabilities
Many injuries occur suspiciously close to the end of the preceding disability period
Disability stems from subjective complaints such as back pain, strain, headaches, etc…
Many of the “treating” providers continually validate the disability yet prescribe little to no actual treatment.

18. Repeat “Accidents” – Real & Falsified
The unfortunate adventures of Mr. Smith
Mr. Smith has had a disability plan with us since 2004
He filed his first claim in late 2004 and has claimed a new disability almost every year since
There are never any witnesses to these alleged “Accidents”
His “Accidents” typically occur months, if not days, after his preceding disability period ends
The physician who “treats” him doesn’t prescribe any tests or physical therapy and there’s no referrals
In the interest of time, we’ll start with his “Accident” in 2007

19. Repeat “Accidents” – Real & Falsified
November 2007 04
Disability Begins
+ $2,500 November 2007
+ $2,500 December 2007
+ $2,500 January 2008
+ $2,500 February 2008
+ $2,500 March 2008
+ $2,500 April 2008
+ $2,500 May 2008
+ $2,500 June 2008
+ $2,500 July 2008
+ $2,500 August 2008
+ $2,500 September 2008
+ $2,500 October 2008
__________________
TOTAL $30,000.00
November 2008 04
Disability Ends
June 2009 01
New Disability
Disability Benefit Period is 12 months
12 Months
7 Months Later

20. Repeat “Accidents” – Real & Falsified
June 2009 01
Disability Begins
+ $2,500 June 2009
+ $2,500 July 2009
+ $2,500 August 2009
+ $2,500 September 2009
+ $2,500 October 2009
+ $2,500 November 2009
+ $2,500 December 2009
+ $2,500 January 2010
+ $2,500 February 2010
+ $2,500 March 2010
+ $2,500 April 2010
+ $2,500 May 2010
__________________
TOTAL $30,000.00
June 2010 01
Disability Ends
July 2010 06
New Disability
Disability Benefit Period is 12 months
12 Months
35 Days Later

21. Repeat “Accidents” – Real & Falsified35
Days
later...
July 2010 06
Disability Begins
+ $2,500 July 2010
+ $2,500 August 2010
+ $2,500 September 2010
+ $2,500 October 2010
+ $2,500 November 2010
+ $2,500 December 2010
+ $2,500 January 2011
+ $2,500 February 2011
+ $2,500 March 2011
+ $2,500 April 2011
+ $2,500 May 2011
+ $2,500 June 2011
__________________
TOTAL $30,000.00
July 2011 06
Disability Ends
July 2011 26
New Disability
Disability Benefit Period is 12 months
12 Months
20 Days Later

22. Repeat “Accidents” – Real & Falsified
After reviewing the records it was determined that we should deny disability benefits as there was no evidence or indication that Mr. Smith was physically unable to work during this time frame. Additionally, Mr. Smith was receiving disability benefits the entire year, but managed to work and make $24, based on his 2011 taxes.
After reviewing the records it was determined that we should deny disability benefits as there was no evidence or indication that the Mr. Smith was physically unable to work during this time frame. Mr. Smith was receiving disability benefits the entire year, but managed to work and make $24, based on his 2011 taxes.

23. Repeat “Accidents” – Real & Falsified Impact to Supplemental Carrier
$90,000 paid over 4 years
Attempted to file another $30,000 claim in 2011
$30, Claim
+ $30, Claim
+ $30, Claim
__________________
TOTAL $90,000

24. Understanding the Claims Process Thank You For Everything You Do!
Questions?