Claims

Information about handling claims with your HRA plan.

Claims run-out

Claims run-out is the amount of time after a plan year ends that we'll continue to pay claims for that plan year. This allows providers more time to submit bills to Priority Health for payment.

The HRA claims run-out period is 12 months (this follows the same rule governing fully-funded health plans), meaning the HRA will continue to pay claims up to 12 months after the date of service. Members must be eligible for coverage on that date of service.

Example: HRA plan year is 1/1/2010 - 12/31/2010. The member went to the doctor on 11/1/2010 but the provider didn't bill Priority Health until 2/1/2011. The HRA will still pay on this claim because the claim was received within 12 months of the date of service.

Processing claims

Claims processing is all automatic with PriorityHRA. Here's how it works:

1. One of your employees seeks a services that is HRA-eligible.
2. The provider bills Priority Health.
3. We will apply the services to the HRA and health plan. If the HRA is supposed to make a payment, we'll mail a check directly to the provider.

You or your employees don't need to submit any paperwork requesting reimbursement.

When there's a claim payment error

HRA pay-out errors

If an HRA overpays because a claim requires reprocessing, overpayment recovery follows these 4 steps:

1. Providers are sent a letter requesting a refund.
2. Refund is initiated by the monthly overpayment statements sent to providers.
3. Providers send refund checks to Priority Health directly. Once the check is received, Priority Health sends you a refund check and an overpayment statement that includes the associated claim detail. Because the HRA is a self-funded plan, we can't reimburse you until we receive the refund from the provider.
4. If the provider hasn't sent a refund check within 120 days, recovery is transferred to an external collections agency.

Repayment and reporting

We request the entire HRA payment back from the provider and replace the entire HRA payment with the correct payment. Because of this, you may see a "duplicate" HRA payment to that provider for a participant's claim. There may be a lag between the corrective payment and recovery of the original payment. The overpayment reimbursement isn't included in weekly funding registers, but is managed outside of the funding process.

Claim payment errors

Most claim payment errors are caused by coordination of benefits (COB). To avoid errors, it's best to report COB situations as soon as possible.

Learn why you should report COB and how it causes errors - go to COB info for members.

Collecting claim payment errors

Priority Health uses AIM Healthcare, a third-party vendor, to identify claims that were paid in error. If we pay a claim that should've been paid by another insurance company and AIM Healthcare discovers the error, they'll recover the money from the provider. When sending that payment to Priority Health, AIM Healthcare keeps about 25% as commission. When recovery happens with an HRA, Priority Health will only return the amount received less commission to you. This is because the HRA is self-funded. Keep in mind that while receiving only a portion of the refund may appear to be a negative experience, without AIM Healthcare, you wouldn't receive any refund at all.