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- Health Insurance Claims
- Questions before you choose
Questions, answered
Answers about policy context, benefit decisions and payment evidence.
Health Insurance Claims
9 questions
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How do I get started?
Click Get started, then use Proto to configure Health Insurance Claims for your business. Pilot one issued policy, one submitted preauthorization and one reported claim with a verified payment event.
How is a claim tied to coverage?
Each claim references a policy. The assessor reads the effective coverage lines and endorsement history against the loss date before preparing the decision.
Who authorizes a benefit?
Claims Decision Reviewer records the decision, reason, authorizing person and approved benefit. Finance uses that approved amount when checking payments.
What happens when more evidence is needed?
The reviewer records a request for evidence and its reason. The case remains available for the next assessment and decision.
Does preauthorization mean a claim was paid?
A preauthorization records an insurer-confirmed request outcome. A paid claim needs a claim decision and verified payment evidence.
How do partial benefit payments work?
Each payment event links to the claim and approved decision. Finance checks the remaining eligible benefit before verifying another event.
How are repeated payment events handled?
Keep the provider event identifier stable. A repeated event should resolve to its existing payment record during reconciliation.
Can staff see work across organizations?
Access should follow the staff member’s organization and assigned responsibility. Test direct record access and internal attachment visibility before rollout.
What drives the cost?
Manual work and machine work follow the published pricing policy. Scope any migration and external connection during implementation.
Set up Health Insurance Claims your way.
Start free, then use Proto to change fields, steps and approvals before your team goes live.