Take a look behind the scenes of claim processing
Published by
Mass General Brigham Health Plan
on
So, you’ve filed a claim—but then what? Where does it go and what happens next? Insurance companies don’t always share what happens behind the scenes, so in the spirit of transparency we're re-sharing this information for anyone that needs a refresher. Below, we walk you through each step at how the average claim gets processed.
Phase 1: Establish our relationship with the provider
First, the insurance company asks:
- Is this provider in our system?
a. Some providers are in our system even if they’re not contracted us. - Is this provider contracted with us?
- Is prior authorization required per contract?
- Does the contract allow for payment of the service?
The answers to these four questions determine either the allowed amount or a contractual denial.
Phase 2: Issue payment & explanation
Next, the insurance company prepares an electronic remittance that includes:
• what we’re paying (we pay providers weekly)• what the member owes
• what’s being denied and why
We use the CARC and RARC for denial codes to ensure everything is clear to the provider— x12.org/reference
Phase 3: Questions and appeals
Then, if a provider has questions, they can use the self-service tools in our portal or call/chat with customer service. That way we can disclose our appeals process, so providers understand denials.
We encourage to visit our policies & guidelines page with links to information that will help you find out which services, treatments, and drugs are covered under our plans.