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Last Updated v12.1.0v1

This screen is used to

lookup plan participants and view Claims, Coverage, Ded/Plan Max, and Transaction history

view network claim information.

***

Employers

Clients with multiple

employer group

client number access can view and search for

members

claims from ANY of the

groups

client numbers permitted under their account.

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Viewing a Participant's Information - Enter information into at least one of the search/filter fields just above the column headings (DOB must be used in combination with another search field). Press ENTER to click the SEARCH. Click on the row containing the participant's information to view their claims and coverage information.

  • For employers with multiple group number access, the Group # search field can be used to narrow the list to a specific group.



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    • Searching Claims - Claims can be filtered by typing in search criteria in the left Claim Search panel.
      • Click the Search button to execute the search process.
      • Once claim results are shown in the results list, the options listed below are available
    The Status field can be used to filter participants in an active or terminated status.  "All" is the default setting and will show both statuses
      • .
      • If the search criteria entered is too broad, the system
    will display a message requiring additional criteria to be entered.  This is done to keep the search time as fast as possible.
      • may take excessive time to return results.  For the best results, please enter as much search criteria as possible.
      • **The results table contains multiple columns and can be scrolled right/left using the scrollbar at the bottom of the results to see more columns.
    • Questions - Use this option to ask questions or fill out forms related to a claim in the result list.  Claim(s) in the result list need to be selected by clicking the checkbox in the "ASK" column of the results row.
      • Question options can vary per client.
      • When the question form is displayed, complete all required fields, any optional fields as needed, and click the Save button to submit the question form.  A transaction ID will be displayed for tracking.  All previously submitted transactions (questions and forms) can be viewed from the My Account\My Transactions main menu option
    Info

    If the Employer/Client account used to access the system is restricted to no claim PHI, the Claims, Ded/Plan Max and HSA tabs will not be visible.  In the screen shots below, the account has full access.

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    • Claims - All claims are shown in order of the select column to sort.  Sort any column by clicking the column header name (Product, Claim No, DOS, etc.)
    • Searching Claims - Claims can be filtered by typing in search criteria below the respective column heading
      • .
    • Export to Excel - Use this option to export all claims currently listed in the grid to an Excel sheet (includes all pages in the grid).
    • Back buttonImage Removed - Go back to the member list.
    Note

    The Charges filter must omit the $ symbol.

    Filtering will happen as the criteria is typed in. There is no need to click any additional buttons to perform the search. Filters can be cleared by removing the search criteria from the boxes.

     

    Paging

    • Paging -Claims in the grid are shown 10 at a time. The bottom of the grid contains the current page being viewed and the total number of pages. The page can be changed by using the forward or back arrows. A page number can also be typed into the current page number box followed by the enter key. The grid will then jump to the given page number.

    Claims

     

    Viewing a Claim - Click anywhere in the row of the claim to be viewed. This will pop up the claim detail screen.

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    Claim - The claim detail screen is valuable for seeing how your claim was submitted from your doctor, and how you claim is paid in accordance with your health plan.

    • Ask a Question - When clicked, a box will be presented to ask a question regarding the current claim being viewed. Enter the question into the “Type Your Question Below” text area. Click the “Ask” button to submit your question to customer service. The status of your question can be viewed at a later date by navigating to MyInfo → My Transactions on the menu.
      • **The Ask a Question button will not be available of the member's employer has disabled this functionality.

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  • Insured EOB - When clicked, a new window will open displaying the actual EOB that was sent to the patient for this claim, or a replica EOB, if the original is not available online.
  • Plan Document - When clicked, a new window will open displaying the corresponding plan document.
    • Please review the Coverage tab for detailed plan and amendment information as well as coverage dates and history.
  • Amendments - When clicked, a new window will open displaying any plan amendment documents (if available).
  • Check Detail - Hover the mouse over the $ symbol next to the "Check" label (PAID claims only).  This will show the check details.
    • View Image Added- The View button provides a selection of claim related documents like Claim Forms and Repricing Sheets.
      • Select an option from the list to view the corresponding document (Not all documents are available for all claims).  

    Viewing Claim Details

    Click anywhere in the Search Results row of the claim to be viewed. This will open the claim detail screen.


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    • View - The View button provides a selection of claim related documents like Claim Forms and Repricing Sheets.
      • Select an option from the list to view the corresponding document (Not all documents are available for all claims).  
    Service Line Detail - Hover the mouse over the ! symbol next to any detail line item (if present).  This will show the explanation of denied charges details.

    Coverage

    The Coverage screen will show demographic and detailed plan coverage information for the selected employee and any dependents on the plan.

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    Name - This area shows name and demographic information about the member.

    ID - This area shows employer and member identification information.

    • Temp ID Card (if available for the employer):  Click this option to see a PDF copy of the member's ID card.
      • Email Card:  Once the ID card is visible on screen, click the EMAIL CARD button to send a PDF copy of the ID card to a specified email address.

    Products - This area shows all covered products and details for the employee.  Select any product row to see the history of coverage for that product.

    • Image RemovedSelect the "View Plan" icon next to each product to display the related plan document.
    • Image RemovedSelect the "View Amendments" icon (if applicable) next to each product to display any available plan amendments or secondary documents.

    Family members - This area shows all dependents that have ever been covered on the plan.  Select any row and the system will update all tabs with that family member's information (Claims, Coverage, Accumulators, and Transactions).

     

    Ded/Plan Max

     

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    • Select the Year and Product to view the deductible, out of pocket, plan maximum(if available), and other accumulator information.
    • Web eXchange shows information for the years the participant has coverage.
    • Click the Plan Document icon to view the related Plan Document (if available).

    HRA (Conditional)

    ***The HRA tab is only available for certain employer groups that have custom HRA information stored on the HealthSmart core claim system.  Web eXchange does not show HRA information from third party vendor systems.  The HRA tab will not display if the member does not have any HRA amounts accumulated in the core claim system.

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    • Select the Year to view the related HRA information.

    COB (Conditional)

    ***The COB tab is only available for certain employer groups that have custom COB information stored on the HealthSmart core claim system.  Web eXchange does not show COB information from third party vendor systems.  The COB tab will not display if the member does not have any COB information in the core claim system.

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    Transactions

     

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    • Any Transactions for this member will be displayed in the grid list.  Filter the list as needed, and select any transaction to view the details.

     

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