Understanding estimates and reimbursement

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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 estimates start with the lower of the session fee and the insurer’s allowed amount.

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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 percentage share of the amount left after any remaining deductible is applied to the lower of the session fee and the insurer’s allowed amount. See how the calculation works.

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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 entire amount used for reimbursement is applied to your remaining deductible. Claim outcomes generally fall into these categories:

• Reimbursed: insurance pays an amount after deductible application and coinsurance. A claim can both finish meeting the deductible and produce partial reimbursement.
• Applied to deductible: insurance approves the claim but applies the entire amount used for reimbursement to your remaining 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 Billing: reimbursement goes to you. Some insurers may mail a check directly to you instead of sending funds through Thrizer.
• Instant Reimbursement: reimbursement goes to Thrizer, because Thrizer already advanced part of the session fee to your clinician.

If Thrizer sends the reimbursement to you, 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. To refresh your deductible progress after new claims have been approved, contact Thrizer 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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Can a recheck change deductible information?

Yes. A new benefit check can return updated deductible information. Thrizer uses usable benefit-check information to estimate costs and determine which payment options are available, while your insurer determines how the deductible applies to each processed claim. If the deductible information shown in Thrizer appears wrong or conflicts with a recent insurer record, request a manual benefit check through Thrizer support.

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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. Estimated deductible credit is limited to the smaller of your remaining deductible and the lower of the session fee and the insurer’s allowed amount.
• 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.

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