Claims
The Claim Document is where processors or data entry make notes regarding what is needed for claim or how it was processed
Where in TIA would you go to see the used Wellness? Pet
Claim>Pet overview tab> used wellness
policy holders who reside in NY or PA, do not qualify to have the cancellation backdated with in the 1st 30 days. The cancellation would be processed by the agents assisting the policyholder, eff the day after the request is made.
Pet was hit by a car. Is this considered an accident or a wellness visit?
Accident
When a claim is closed and new information is received.
Where do we route the claim and which action ID do we use?
CLACLR Action #50
Once a claim has been processed, TIA will send out the Explanation of Benefits
Where in TIA would you go to see how much has been applied to the deductible, how much is remaining of the deductible, what has been used towards the annual limit and what is remaining of the annual limit ?
Claim > Pet overview > Used Annual
No, If the claim was covered (reimbursed or applied towards the deductible) you will process the cancellation effective the day after the request was made. The policyholder will receive a pro-rated refund for any premiums paid for in advance.
The pet had a wellness visit and during the exam the pet was also diagnosed with an ear infection. Will this be processed as an Accident/Illness or Wellness claim?
The claim will be split between both Accident/Illness and Wellness. The items approved on the invoice for illness will be applied towards the deductible. The wellness items will go towards any remaining wellness benefits if available on the policy.
When a claim was processed as wellness and was supposed to be processed as illness.
Where do we route the claim and which action ID do we use?
Action #10 > CUSTSAT for a claim review.
What Action ID would be used to close the case item for a Claim Inquiry if no routing is required?
Where in TIA would you go to see how much has been applied to the deductible, how much is remaining of the deductible, what has been used towards the annual limit and what is remaining of the annual limit ?
Claim > Pet overview > Used Annual
Prior to cancelling a policy, what should we advise the policyholder? (This should also be documented in your notes)
CX Script
Will the wellness visit go towards the applicable deductible?
NO, wellness has it's own set of Limits.
A claim is currently in process and new information has been received. EXAMPLE: past DVM Hx, Vx, Hx, adoption date.
Where do we route the claim and which action ID do we use?
Action #50 CLACLR
New information received Invoice/Pets History
Policy Holder request to close the claim
What should you do, if you see that the policyholder has filed a dispute with the credit card company or bank?
Inform the policyholder that they will receive a cancelation confirmation in 24-48 business hours.
Route the CI to CARDDISP in TIA
Send Lucretia Adams a message in Teams with the policyholder's name and policy number so she knows you’ve routed it over for cancelation.
A pet was hit by a car and their Cruciate ligament was injured and the pet needs Surgery. Will this be covered under an accident Accident only policy with wellness ?
No, unfortunately, under any circumstances, a cruciate ligament is not covered under an accident-only policy with wellness.
The policyholder received their EOB after the claim was processed and there were invoices missing from the original submission.
Where do we route the claim and which action ID do we use?
Claim will need to be sent for review to CUSTSAT Action #10
When a claim is denied for lack of Medical records and closed out .Is the claim reopened or is a new claim produced?
A new claim will be generated once the claim is reopened and a new claim # will be assigned
Where in TIA would you go to see the notes on the claim, when medical records were requested, when medical records were received, and when an Explanation of Benefits was sent?
claims tab -cases The claim cases screen
Pet just had surgery for a spay. While in recovery pet pulled out their stitches' and had to be seen for an infection. Policy holder does not have wellness on the policy. Will we cover the complications due to the spay?
No,coverage will only be extended,If the policy has Best wellness and they are outside of the Medical waiting period.
The claim was closed for Periodontal disease restrictions under APIC . PH calls after uploading medical records from the past 13 month.
Where do we route CI and which action ID do we use?
Since the claim was closed we need to send the documentation to CUSTSAT Action #10 for review to be reprocessed per new information received.