Balance Billing
Flow chart and explanation for Balance Billing
Index
Balance Billing Definition
Balance Billing: when a provider’s bill includes a charge for the portion of the claim that is supposed to be discounted.
Make sure the policy and claim are eligible before proceeding.
Eligibility for Assistance
Assistance is available only if:
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The policy is an open-access Pivot Health plan.
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The services were determined to be eligible expenses.
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Eligible expenses include services applied to the deductible or paid, but not denied medical services.
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The provider is refusing to accept the discount.
How to Submit a Bill to Balance Billing
Email clientservices@insurancebenefitadministrators.com with the following information:
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Subject Line: Balance Billing
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The bill from the provider (attached)
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Member’s name
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Member’s ID
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Claim number
Balance Billing Flow Chart
Step 1: Collect & Verify Member Information
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Ask:
“Can I please have your ID number?”
“May I have your name and date of birth?”
Step 2: Collect Claim Information
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Ask:
“Can you provide the date of service and billed amount for this claim?”
Step 3: Check for Updates
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Review Contact for logged updates.
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Look for activities with Balance Billing + claim number.
Always check here for progress before moving forward.
Step 4: Check if Balance Billing Process Completed
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If Yes:
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Say:
“It looks like your claim reprocessed, and there is now a new EOB available. Would you like me to send that to you now?”
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If No:
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Say:
“It looks like your claim is reprocessing, but the EOB hasn’t quite generated yet. Please allow a little more time for the claim to finish processing.”
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Step 4 (Alternative): Check Zelis Claims
If AI/HubSpot doesn’t have the latest information:
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Hover over Claims > Claim Research & Resolution > Research Inventory.
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Narrow by Search Type: CLIENT and select appropriate Date Range.
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Provide caller with the most recent update.