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Overview

Thrizer uses available benefit information to estimate out-of-network costs. Those estimates help you plan, but the insurer determines the final claim result.

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Key terms

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Provider fee

The provider fee is your clinician’s full session rate.

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Allowed amount

The allowed amount is the amount the insurer recognizes for a covered service. Reimbursement is based on the allowed amount, not necessarily the provider fee.

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Deductible

Your deductible is the amount you pay before insurance starts reimbursing eligible services. If your deductible is not met, an approved claim can apply to your deductible and still pay $0 in reimbursement.

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Coinsurance

Coinsurance is your share of the allowed amount after the deductible is met.

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Why estimates change

Before a claim is processed, Thrizer estimates the allowed amount and reimbursement using available benefit information. After the insurer processes a claim, Thrizer updates expectations based on the insurer’s actual allowed amount and claim result.

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Approved does not always mean reimbursed

A claim can be approved and still result in $0 reimbursement when the allowed amount is applied to your deductible. Claim outcomes generally fall into these categories:
  • Reimbursed: insurance pays part of the allowed amount.
  • Applied to deductible: insurance approves the claim but applies the allowed amount to your deductible instead of paying reimbursement.
  • Denied: insurance does not issue reimbursement or deductible credit.

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Who receives reimbursement

Where reimbursement is sent depends on the payment option used for the session:
  • OON Pay: reimbursement is sent to you. Some insurers may mail a check directly to you instead of sending funds through Thrizer.
  • Superbill upload: reimbursement is sent to you.
  • Thrizer Pay: reimbursement is sent to Thrizer, because Thrizer already advanced part of the session fee to your clinician.
If reimbursement is sent to you through Thrizer, add a reimbursement bank account so Thrizer knows where to deposit funds.

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Does Thrizer track my deductible progress?

Thrizer does not automatically track a running deductible balance across claims. Benefit checks estimate deductible status at the time the check is run. The insurance carrier determines deductible application on each claim when it processes the claim. You can initiate a manual recheck of your deductible progress after new claims have been approved:
  1. Go to client.thrizer.com/settings/insurance.
  2. Select Recheck.
If the recheck does not work, contact Support and ask for a manual recheck. For the most accurate, up-to-date deductible balance, contact your insurance carrier directly.

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Will a recheck ever undo a met deductible?

Not in the same calendar year. Automated benefit checks often report the plan-level deductible remaining and do not reflect the out-of-network payments you have already made toward it. To avoid incorrectly flipping a met deductible back to not met, Thrizer preserves the previously recorded met value for the rest of the calendar year. The discrepancy is flagged for internal review. A recheck can change your deductible status in these cases:
  • A new calendar year. Most out-of-network plans reset on January 1, so a recheck in the new year is allowed to show the new plan-year deductible as not met.
  • You update your insurance to a different plan or payer. The previous plan’s deductible no longer applies. The new plan’s deductible is used going forward, even if the previous plan’s deductible was met.
If your deductible should be marked as met and it is not, contact Support so the recorded value can be reviewed.

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Why an OON claim may not appear to count toward your deductible

When a claim is processed, the insurer decides how the allowed amount is applied. Common reasons an OON claim may not appear to reduce your deductible balance:
  • The claim is still processing. Deductible application is not final until the insurer finishes processing the claim.
  • The claim was denied. A denied claim gives no reimbursement and no deductible credit.
  • The allowed amount is different from the session fee. Deductible credit is based on the insurer’s allowed amount, not the full amount your clinician charged.
  • Your plan applies out-of-network costs to a separate out-of-network deductible. Some plans track in-network and out-of-network deductibles separately.
  • The insurer’s records are not yet updated. Deductible balances shown by your insurer can lag behind recently processed claims.
If a claim has been processed and you still have questions about how it was applied, contact your insurance carrier — they determine final deductible application.

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Timing

Insurance claims commonly take several weeks to process. The insurance carrier controls actual timing.

Reimbursement basics

Learn how out-of-network reimbursement generally works and why estimates can change.

Deductibles, coinsurance, and allowed amounts

Understand the insurance terms that most directly affect what you get reimbursed.

Why an approved claim may not pay reimbursement

See why an approved claim can still result in $0 paid back to you.

Why reimbursement can differ from the estimate

Learn why the final insurer decision may not match the estimate you saw before the claim was processed.

Adding a reimbursement bank account

Add or update the bank account Thrizer uses to send reimbursement to you.

Claims processing timeline

See what happens after a claim is submitted and why timing depends on the insurance carrier.