If you’ve used the TELUS eClaims portal in the past, you’re likely familiar with those “pending” or “on hold” claims. When the insurance provider has successfully received the claim, they generate this type of response letting you know they cannot provide an in-the-moment decision.
In these cases, the insurer will provide you with their decision at a later date, outside of Jane (i.e. over the phone or email). These claims won’t update automatically, nor will you receive any notifications on the status of the claim through Jane. Insurers don’t typically send these types of adjudications back through the integration, since that’s their preference.
To resolve these claims, you’ll first want to contact the insurer directly to confirm what their final decision is. The Explanation of Benefits (or EOB for short) will sometimes provide the time the insurer needs to complete their assessment of the claim, including their contact information.
If they don’t provide an exact timeframe, you can contact the insurer directly within 24 to 48 hours of the submission. Once they confirm the status, details of the amount covered (or not covered) and who can expect payment, you can update the claim manually.
Whether you’re being paid for the visit or the patient is directly, let’s go over how to manage these for each situation
Paid to Clinic
If the clinic ends up receiving the payment you’ll be able to manually record the amount received once you get that information in your statement from the insurer:
In the event that the insurer does not pay the full cost of the visit you can specify the actual amount paid in the first step of receiving the payment and on the second step this will only partially pay the invoice:
Then Jane will give you the option to bill the remaining balance to the patient:
Paid to Insured Member/Patient
If the patient is the one who receives the payment in the end and this is specified in the EOB that Jane receives - Jane will actually update the insurance mode on the visit to be Patient Pre-Pay which will automatically push the full balance of the visit to the patient to pay up front.
For dealing with the insurer invoice, clinics will typically mark the claim as “Paid & Approved” once the patient has been paid by insurance. Or some clinics will just mark it as “Paid & Approved” right away if they are confident that the patient will receive the payment.
To mark the claim as “Paid & Approved”, you can do so from the Submitted folder, the patient’s profile or the insurer invoices area by clicking the black arrow next to the line item and select the Pay & Approve option:
When you select this option, Jane won’t actually record a real payment from insurance so you won’t see these payments on any of your reporting. Instead, she will just move it to the Approved folder.
You can also choose to completely remove the claim from the appointment which will turn it into a fully private visit since you will not be receiving anything from the insurer yourselves. With this option you would lose the record of your original submission though.