For many benefits, members can submit claims for reimbursement. Admins can request additional information, approve, or deny.
How to review claims
Review permissions
Tier-two agents, partner admins, and partner super admins can review claims. To learn more, check out “Create and manage partner administrator accounts.”
Go to the Claims tab.
Open the appropriate claim.
Select Start Reviewing. (This lets other admins know that someone is working on this claim.)
Review claim details to ensure the expense is eligible and aligns with plan rules.
Select Approve, Deny, or Needs Information
Decision communications
Members will be notified of claim decisions, unless notifications have been disabled based on partnership agreements.
Approving claims
You can choose to approve a claim in full for the amount requested or approve a claim in part. When approving a claim in part, you'll enter the approved amount and select the denial reason for the remaining amount. The reason will be shared with the member. Approvals are final. If the approved amount needs to change, the member will need to submit a new claim.
Requesting more information
If you need more information to approve a claim, you can request additional information from the member. After you select the needed information, the member will receive a claim update with your request.
Denying claims
When denying a claim, choose the appropriate reason for the denial. The reason will be shared with the member. Members can appeal denied claims.
Plan and member details
To review plan details, select the plan name next to Benefit in Claim Details. Here, you can answer questions like:
Plan Details: Does the plan have an extension period? A receipt requirement
Eligible Expenses: What categories of expenses are considered eligible
Merchant Category Code: Where will the card be accepted?
To review member information, select the member’s name next to Member in Claim Details.
Review claims by member
You can also review claims by member. To access this view, go to the member’s page, choose the appropriate benefit, and then select Claims History.
Claims activity
To review claim history and internal notes, scroll to the Activity tab of the claim.
Understanding the claims dashboard
The claims dashboard shows claims by unresolved or resolved status.
Unresolved and resolved
You and your team will likely spend most of your time working in the Unresolved tab, where you can review submitted claims. The Resolved tab is where you can see all approved and denied claims.
Claims snapshot
The unresolved claims snapshot gives you a quick overview of your team's progress and workload, as the view filters unresolved claims by status and their time in the queue.
Claim statuses
Here is an overview of the possible claim statuses.
Status | View | Definition |
New | Unresolved | Unopened new claim |
Updated | Unresolved | Claim resubmitted with requested info |
In Review | Unresolved | Admin is reviewing the claim |
Information Requested | Unresolved | Admin returned claim to member for additional information. |
Approved | Resolved | Admin has approved claim in full |
Payment Pending | Resolved | Payment process has been initiated |
Paid | Resolved | Payment has been made |
Denied | Resolved | Admin has denied the claim |