{"id":1229,"date":"2024-04-26T15:10:39","date_gmt":"2024-04-26T22:10:39","guid":{"rendered":"https:\/\/immixgroup.ca\/blog\/?p=1229"},"modified":"2024-04-26T15:39:41","modified_gmt":"2024-04-26T22:39:41","slug":"claim-confusion","status":"publish","type":"post","link":"https:\/\/immixgroup.ca\/blog\/2024\/04\/26\/claim-confusion\/","title":{"rendered":"Claim Confusion"},"content":{"rendered":"\t\t
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Claim Confusion: Common Reasons Why Your Benefits Claim May Leave You \"Out-of-Pocket\"<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
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Uncovering why you may be left \u2018out-of-pocket\u2019 when claiming under your benefits program <\/strong><\/p>\n

Wondering why you\u2019re left \u2018out-of-pocket\u2019 despite having a robust benefits program? There is nothing more frustrating than submitting your claim, only to find it\u2019s not covered, or not covered up to the level you expected.<\/p>\n

Here are some common scenarios that explain why your reimbursement might fall short of your expectations.<\/p>\n

<\/p>\n

Is it just the plan design?<\/h4>\n

Of course, benefits programs differ significantly from employer to employer<\/a>. Often, the reason for a decline is simply the plan design selected by your employer. While a previous employer may have included certain items, your current employer may have opted to exclude the item.<\/p>\n

Largely speaking, while insurance companies have varying default plan provisions, most can customize coverage to meet the employer\u2019s preferences. For example, there is a broad range of paramedical practitioners that can be included, beyond the standard practitioners that most people expect to see. Less common practitioners such as Dieticians, Athletic Therapists, Kinesiologists, and Clinical Counsellors can often be included, but may not be standard for the provider.<\/p>\n

While the blame is typically placed on the insurance carrier, more often than not, a decline has nothing to do with the carrier\u2019s ability to cover something, but rather to do with the plan design implemented by the employer, based on a range of factors such as benchmarking information, budget, employee feedback, coverage availability for the industry etc. That said, there are many common rules and plan parameters, as outlined below, that are often the reason for a decline.<\/p>


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Is it the timing?<\/h4>\n

Many items have frequency limits attached to them, or a certain duration of time that must pass before you can claim the item again.<\/p>\n

Understanding how the limits are applied is especially important. For example, does the benefit period apply to the calendar year (i.e. 2 calendar years apart), or at the 24-month mark from when the service was last claimed?<\/p>


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Routine Dental Visits  <\/h4>\n

The most commonly known frequency limitation is the \u20186-month recall\u2019 often attached to routine dental visits. In short, this means that a routine exam and cleaning will only be covered every six months. If you book an exam too soon, your coverage will likely be declined. To clarify, if it is determined during a routine visit that you require follow-up procedures such as a filling, this does not mean you need to wait 6 months for the filling. It is only the routine exam that falls under the 6-month recall frequency limitation.<\/p>\n

Some programs use a 9-month recall in order to help reduce costs. If this is not communicated, you may find yourself un-insured if your recall exam takes place too soon.<\/p>


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Vision Care Cycles<\/h4>\n

Vision care is commonly run on a 2-year or 24-month cycle, and the distinction is important. For example, your plan might provide vision care coverage defined as one of the following:<\/p>\n