WPS behind the scenes: How claims are processed

You go to see the doctor. You know how that goes: You check in with the receptionist, who takes your insurance information. You sit in the waiting room for a few minutes. You get called back to an exam room. You visit with the doctor. The doctor tells you what you should do to get or stay healthy. You go home and follow the doctor’s orders.

But wait. Somehow, the doctor has to get paid. That’s where your health insurance comes in.

A person in your doctor’s office typically submits a health insurance claim on your behalf, although there are times when you may have to submit a claim yourself. The claim lists the amount billed and what services were provided. Some of the information is in code. The claim goes to the health insurance company you shared with the receptionist for payment. Here’s what happens when the claim goes to WPS Health Insurance.

Claim submission

WPS receives the vast majority of claims from providers. Only a handful each month are submitted directly by customers. Many of the claims—about 85%—are processed electronically. That means employees don’t have to touch them unless there’s some kind of issue. Some claims are submitted on paper, and those are entered into the processing system by a small team at WPS.

Claim processing

WPS processes about 500,000 claims per month. Each one takes about 10 days to go through the process. They’re checked for a variety of requirements. Some include:

  • Was the claim submitted properly?
  • Is the claim coded properly?
  • Were you covered by your health plan on the day you saw your health care provider?
  • Is the health care provider in the network?
  • Is the claim a duplicate of a previously submitted claim?
  • Is the service cited in the claim covered by the policy?
  • Was it filed in a timely fashion?

If a claim fails to meet a requirement, it gets pulled aside for review. Claims may be denied for many reasons, such as if your doctor took too long to submit the claim or if a service you received wasn’t covered by your health plan. Your claim may also be denied if a prior authorization for a service was required but not submitted.

If you’ve ever had a claim get denied, it can feel frustrating. If you have questions on why a claim was denied, you can call our Customer Support team at the number on your WPS ID card.

Your EOB

After a claim is processed, the insured customer is sent an Explanation of Benefits, or EOB. This document shows your deductible amounts, out-of-pocket amounts, and includes a detailed summary of your medical claim.

The EOB is not a bill but does show you what your billed amount will be. It’s the document you can use to double-check a bill received from your health care provider. If you have any questions, you can call WPS Customer Support using the phone number on the EOB or, again, the number on your ID card.

Behind the scenes

As you can see, a lot happens behind the scenes after you visit your doctor. Remember that WPS Health Insurance is here to help you, because we care about making sure you get the right care to stay healthy. If you ever have any questions, give us a call using the number on your WPS ID card. We can assist you as you navigate the health care system.

©2020 Wisconsin Physicians Service Insurance Corporation. All rights reserved. JO17020   34967-100-2003

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