Care management & claims

A claimant's experience and quality of care is at the heart of everything we do.

Care management means providing the right care at the right time in the right way by the right provider. This requires getting involved early on in the claims process to find high-quality, medically correct services for claimants to ensure they are getting the care they need.

Our care management team achieves this by advocating for our claimants—interacting with physicians and other health care practitioners, providers, insurance carriers, billing offices, and claims processors—and making the quality of care they receive our highest priority.

We also recognize that care needs can and do change over time and regularly verify that the appropriate care is being performed to help reduce unnecessary costs and the possibility of fraud.

Our care coordinators

Acting as individual care managers for long term care claimants and their families, our care coordinators are registered nurses (RNs) who offer an unbiased resource for families to consult with at the often difficult time of finding the right care for a loved one. We are a team of compassionate, care-centered experts who provide the following services:

  • Comprehensive claims assessment and benefit eligibility determination
    Once an enrollee initiates a claim, we gather the information and documentation necessary and arrange for an in-person assessment to decide if they are eligible to begin receiving benefits. We also have a recertification process to continue to monitor an enrollee's benefit eligibility and an appeals process for enrollees who disagree with our claims decisions.
  • Development of personalized plans of care
    We develop and monitor plans of care for benefit eligible enrollees, searching for and recommending providers, and coordinating a team of health professionals and support services to address care needs. We also reassess plans periodically to ensure that the amount and type of care designated by the plan remain appropriate for the claimant's needs, and update them as circumstances warrant.
  • Access to a discount provider network
    Using a database of more than 250,000 providers, we identify and provide claimants with options for local caregivers and sites of care on request. We can also validate if a provider's license is in good standing according to state and federal regulations, review a provider's professional liability insurance claims history and outcomes, and highlight any accreditations they may have. We typically negotiate a discounted rate for the majority of our claimants, with provider discounts ranging anywhere from 2.5% to 25%.
  • Ongoing claims monitoring
    To ensure that a claimant's needs are being met and their circumstances and priorities have not changed, we provide ongoing monitoring of claims.

Claims processing

Fast and accurate claims processing, for both claimants and providers, ensures continuity of care for enrollees who are ready to use their benefits. At the same time, we recognize the importance of establishing controls that prevent misuse in order to protect the program, the carrier, and the claims experience as a whole.

We're committed to maintaining this balance between monitoring the integrity of our enrollees' claims while providing claims processing services that meet the highest standards of quality. These services include:

  • proactive enrollee communications and workflow to guide and manage claimants' expectations throughout the claims process
  • ongoing needs assessment, care advisory, and fraud detection
  • informal and home health care management and controls
  • claims payment and explanation of benefits (EOB) processing
  • provider reimbursement and appeals
  • online access to claims history, authorization forms, assignment of benefits, and invoices
  • custom claims experience tracking and reporting
  • fraud risk management, controls, and prevention
  • defined service metrics and turnaround times for benefit eligibility decisions and claims payments that ensure prompt and accurate payments for claimants

Partner with us

We currently administer employee benefits supporting more than four million enrollments and partner with more than a dozen national insurance carriers, including several Fortune 500 companies. We are a wholly owned subsidiary of John Hancock, one of the oldest and most trusted of all U.S. insurers. Find out how we can put our expertise to work for you.