Claims Communications

Turn routine communications into meaningful touchpoints.

Consolidating transactional claim communications with Episodic EOBs® to provide clarity to members while reducing volume and costs.

Your members should understand their healthcare benefits and their individual financial responsibilities. There shouldn’t be any confusion.  That’s why we’ve created DOCS®, a self-service platform for you to provide clear, concise and understandable communications. Consolidating transactional claim communications with Episodic EOBs®, delivered in their preferred way, reduces member confusion by making it easy for members to understand what they owe.

Claims Communications help you:

Move from transaction to episodic claims communications
Consolidate mailings, even from multiple partners, to save postage
Coordinate EOBs with provider adjudication schedules for improved billing accuracy
Customize designs and messaging via self-service web portal
 

The No Surprises Act, Transparency Requirements, and Claims Communications

Member ID

With the roll out of the No Surprises Act (NSA), new requirements for member ID cards and Advanced Explanation of Benefits (AEOB) communications have been introduced.

For plan years beginning January 2022 or later, NSA now requires that member ID cards (both electronic and print) include the following:

  • In-network (INN) deductible
  • Out-of-network (OON) deductible
  • Out-of-pocket maximum limit
  • Telephone number for member assistance
  • Website URL for member assistance
  • Information on where to find INN providers

How Zelis can help
Here at Zelis we’re adapting our ID card communications, delivering NSA-ready cards on behalf of clients by designing templates to each payer’s compliance specifications and the required fields shown above.

 

Advanced EOBs (AEOBs)

NSA has also affected AEOBs (applicable to all services, in- and out-of-network, by providers and facilities). Requirements must be fulfilled when an appointment is made for services and when requested by the member, even without an appointment.

For every scheduled service and upon member request, the payer must provide the member with an AEOB that includes:

  • Whether the provider or facility is a participating provider (INN), and the contracted rate for the item or service
  • If the provider or facility is OON, description on how to find information on INN providers
  • Good faith estimates for each of the following:
    • Provider billed charges (sent by the provider)
    • Amount the payer is responsible for paying
    • Member’s cost-share responsibility
    • Amount the member has incurred toward meeting deductibles and OOP maximums
    • A disclaimer that coverage is subject to medical management, if applicable
    • Any other applicable information or disclaimer

How Zelis can help
Using client-provided data, we work with payers to create NSA-ready templates for AEOBs (in both print and digital format), while supporting increased claim volume and distinguishing between pre-service estimates and claims for received care.

Moreover, we can:

  • Enhance the quality of estimations through our out-of-network estimations and Machine-Readable Files (MRFs)
  • Improve searches by adding provider network affiliation data
  • Enable a complete fulfillment solution by supporting print delivery of AEOBs

Learn More

To further explore NSA compliance and realizing the benefits of a digitization strategy, reach out to your Zelis representative or contact us here.

For access to additional information, visit Zelis’ No Surprises Act Information Hub.