Claim It Like You Mean It
What is the first thing a policyholder must do after paying for vet services?
Obtain an itemized invoice.
What type of policy lists what is not covered rather than what is?
Named Exclusion Policy.
What is the first thing eligible charges apply to?
The annual deductible.
What does the status “Received” mean?
Claim has been received but not yet assigned.
What should you do before recommending an appeal?
Review medical records, EOB, and terms and conditions.
What types of documents are required to file a claim?
Itemized invoice with date of service, pet name, owner info, hospital name, and all pages.
What does denial code D4 mean?
Condition or date of service is pre-existing to policy coverage.
What does “up to limits” mean in the context of reimbursement?
Reimbursement is capped at the policy’s maximum payout.
What does “Mail Back” status indicate?
Insufficient information; claim returned to policyholder.
What’s a common reason a claim should not be appealed?
Condition is pre-existing or excluded by policy.
What are the acceptable methods for submitting a claim?
Email, fax, postal mail, or customer portal.
Why should you never guarantee eligibility to a policyholder?
Because eligibility is based on terms and conditions and medical records.
If a policy has 20% co-insurance, what percentage is reimbursed?
80%.
What does “Closed Pending” mean?
Awaiting additional info like diagnosis or vet records.
What documents are needed for a valid appeal?
Claim Re-determination form, medical records, vet’s signed statement.
Why can’t a credit card receipt be used instead of an itemized invoice?
It doesn’t show the services/products or itemized charges.
What does it mean when a condition is considered pre-existing?
It occurred before coverage started or during the waiting period.
What happens when a claim exceeds the lifetime incident limit?
No further reimbursement for that condition or related issues.
What should you never do when a claim is in audit/finalized status?
Share the “Amount Paid” listed—it may change.
What should you explain if the condition was diagnosed before coverage started?
It’s pre-existing and not eligible for coverage.
What happens if a claim is submitted with a handwritten invoice?
The adjuster will contact the animal hospital to confirm totals.
What should you do if a policyholder insists the medical records are incorrect?
Advise them to speak with their vet; medical records are legal documents.
How does dual coverage affect reimbursement when we are the secondary provider?
We reimburse only the excess amount not covered by the primary insurer.
What does “Void” status mean?
Claim was entered incorrectly, duplicated, or processed under an old system.
What should you do if the invoice and medical records conflict about the nature of the visit?
Explain that invoices and medical records are legal documents and cannot be changed.