7 Paying claims

Question 1

5 stages of claims process

Answer 1

1. Visit to GP and contacting insurer for pre-authorisation
2. Specialist determines and carries out required treatment
3. Claim form and bills submitted to insurer
4. Insurer processes claims
5. Insurer pays provider and notifies customer

Question 2

Reasons an insurer may refuse to authorise treatment

Answer 2

1. Onset of condition started before policy
2. Claim relates to a time before the policy began
3. Treatment not likely to be effective
4. Treatment previously has not been effective

Question 3

Who monitors fairness of insurance policies?

Answer 3

FOS

Question 4

Direct settlement agreements

Answer 4

Contracts with hospitals, where all costs are settled with the hospital on a regular basis

Question 5

4 benefits of direct settlement

Answer 5

1. No need for customer to arrange payment
2. Customer knows hospital is covered
3. Hospitals get paid quickly
4. Insurers can obtain competitive rates

Question 6

Downsides of direct settlement

Answer 6

1. Claimants detached from cost control process
2. Part payments

Question 7

What happens if a patient has treatment for which they are not eligible or has not been pre-authorised?

Answer 7

The patient must pay

Question 8

5 Advantages to electronic billing

Answer 8

1. Faster process
2. Data checks
3. No paperwork
4. Early notification of shortfalls
5. Lower claims costs

Question 9

Healthcode Ltd

Answer 9

The UK’s official medical bill clearing company

Question 10

What does the insurer look at when assessing a claim?

Answer 10

1. Benefit entitlement
2. Previous claim history

Question 11

Partnership consultants

Answer 11

Hospital consultants that adhere to insurer fee schedules

Question 12

Eligibility checks

Answer 12

1. Have all premiums been paid?
2. Maximum limits?
3. Exclusions?
4. Underwriting
5. Specialist eligibility

Question 13

2 part of payment determination

Answer 13

1. The amount of payment to be made
2. To whom the payment should be made

Question 14

Impairment codes

Answer 14

WHO ICD codes

Question 15

OPCS

Answer 15

Office of population, Censuses and Surveys (or ONS)

Question 16

CCSD codes

Answer 16

Clinical Coding and Schedule Development – over 2,000 procedures – each treatment given its own code

Question 17

Consultant

Answer 17

Someone who holds a current NHS consultant contract

Question 18

Session definition

Answer 18

A notional half day

Question 19

QIPP abbreviation

Answer 19

Quality, Innovation, Productivity and Prevention initiative

Question 20

Small value high frequency cash plan claims

Answer 20

Completion of a simple claim form and original receipt – heavily automated.

Question 21

Known provider health cash plan claims payment

Answer 21

Claims may be paid directly to the supplier

Question 22

Cash plan higher value claims payments

Answer 22

Automated payments, but with greater checking

Question 23

Cash plan third party claim payments

Answer 23

Often wholly or partly handled by the third party

Question 24

Dental insurance claims payments

Answer 24

Customer pays dentist and claims back from insurer

Question 25

HICFG abbreviation

Answer 25

Health Insurance Counter Fraud Group (HICFG)