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A Case Study In Medical and Supplemental Claims Integration


THE CUSTOMER: Hawaii’s largest provider of marine terminal services.

This USAble Life customer employs some of the hardest working people in Hawaii ― hundreds of dockworkers who load and unload cargo from the many major national and international commercial ships that port in Oahu and the island of Hawaii.

This company is one of the growing number of employers to add supplemental products to their overall benefits program. USAble Life provides accident, hospital, critical illness, and life coverage to the company’s 700 employees. Blue Partner, Hawaii Medical Service Association (HMSA), is the company’s primary medical insurance carrier.

THE OPPORTUNITY: Developing a quick and easy supplemental claims process.

USAble Life and HMSA worked collaboratively to develop a HIPAA-compliant, unique solution specific for this customer. The solution has HMSA securely share authorized medical claims with USAble Life and eliminates the need for employees to go through the somewhat arduous process of filing a claim, which includes an employee statement, a physician’s statement, and an employer statement to verify employment. The physician statement, in particular, can be time-consuming for the employee to get completed, often requiring multiple follow-ups with physician offices.

With medical claims in hand, USAble Life was able to develop approaches to turn medical claims into accident, hospital, and critical illness benefit payments, eliminating the need for any claims forms in the majority of scenarios.

“Without the close working relationship with our Blue Partner, HMSA, this would never have worked,” said Rich Macy, USAble Life Chief Operating Officer. “Our experience working with Blue Partners ― how to leverage Blue systems and processes for the benefit of our joint customers ― is absolutely key. This is just one example of what we’re capable of doing together.”

THE INNOVATIVE SOLUTION: HMSA medical claims drive USAble Life supplemental benefit payments.

Since 2016, HMSA has shared authorized medical claims data with USAble Life and matches procedure and treatment codes provided in the medical claims file as the basis for paying supplemental claims.

Here’s a scenario to illustrate how the process works:

John receives his regularly scheduled colonoscopy. Based on the medical claims data, a supplemental claim is triggered for a wellness diagnostic incentive benefit. John qualifies to receive a check in the mail from USAble Life, rewarding him for compliance with preventive care. With HMSA and USAble Life processing, John receives his benefit without the extra effort on his part. Because of the typical paper process involved, John may not have filed a claim.

Today, more than nine in 10 eligible claims are automatically paid with no claim form, employer or physician statement. In 2018, more than 11,000 automatic payments were completed.

THE RESULT: Hawaii’s heavy-lifting employees receive the benefits they deserve without lifting a finger.

For this employer, over 90% of claims are processed automatically and paid with no employee, employer, or physician. For most benefit payments, employees no longer have to initiate a claim and no paperwork is required ― a drastic improvement in the experience that also ensures they get the maximum benefit under their policies.

Interested in learning more about integrated claims? If you have questions about integrated claims or would like to learn more about our capabilities, email us at partnerservice@usablelife.com