Real claims scenarios

Scenario 1: Pre-Authorization of a Medical Procedure - Direct Payment to Medical Facility

April 12, 2021

Client Contacted Guardian

- Client contacted Guardian Claims Department to inform us of a necessary surgery, and requested pre-authorization and for the expenses to be paid directly to the facility by the insurance provider.

-Guardian Claims Department contacted the insurance company to inform them of this and to ask what documents we needed to provide.

-The insurance company replied to Guardian Claims Department with the list of necessary info to proceed with the pre-authorization of the procedure. This info included medical notes on the condition, the medical order from the doctor, date and place of procedure and a medical fees breakdown (surgeon fees, anesthesiologist fees, assistant surgeon fees).

April 27, 2021

Client sent documents

Client sent all documents that were requested to our Guardian Claims Department, but the expense breakdown was missing. We requested that from the client again.

May 3, 2021

Client sent us the expense breakdown

-Client sent us the expense breakdown.

-The insurance company requested further information (MRI and a medical report including info of the beginning of the medical issue, including date of first diagnosis, etc.).

May 5, 2021

Client submitted MRI

Client submitted MRI and medical report, but it was missing a doctor signature and some other information, so we requested that from the client

May 11, 2021

Client sent medical report

Client sent the complete medical report with doctor signature and missing info.

May 13, 2021

All information submitted

With all information submitted, the insurance company sent the Guarantee of Payment Letter.

May 15, 2021

Client had successful surgery

Client had successful surgery, which was paid directly to the facility by the insurance company.

Total amount Paid Directly to Hospital: $35,935.82 USD

Total Claim proccesing time: 33 days

Scenario 2: Preventive Check-Up Reimbursement to Client

June 9, 2021

Client sent documents

- Client sent Guardian Claims Department their documents to submit to the insurance company for reimbursement. The documents submitted were the doctor order, lab results, proof of payment and the medical report from the doctor, based on the lab results.

June 10, 2021

Guardian submitted documents

Guardian Claims Department submitted the documents to insurance company.

June 17, 2021

The insurance company replied

The insurance company replied confirming receipt of the documents.

June 20, 2021

The insurance company emailed Guardian

The insurance company emailed Guardian Claims Department asking for the client’s bank info to make reimbursement payment.

June 30, 2021

Guardian sent Information

Guardian Claims Department sent client bank info to the insurance company

July 20, 2021

The insurance company reimbursed

The insurance company reimbursed total amount of preventive checkup expenses to client.

Scenario 3: Reimbursement to Client for Prescription Medication after Meeting Deductible

June 11, 2021

Guardian Claims Department received the medical report, doctor prescription and the payment receipt from the client.

June 14, 2021

Guardian Claims Department sent the documents to the insurance company.

June 21, 2021

The insurance company replied confirming receipt of the documents.

July 14, 2021

The insurance company reimbursed the prescription medication expenses in full to client.

Total Amount Reimbursed to Client: $7,638 MXN
($382 USD)

Total claim processing time: 33 days

Scenario 4: Applying Expenses Towards the Annual Deductible

August 17, 2021

Client suffered minor accident and sent Guardian Claims Department the necessary documents, including payment receipts, itemized bill and medical records.

August 17, 2021

Guardian Claims Department sent that documentation to the insurance company.

August 26, 2021

The insurance company confirmed receipt of the documents.

September 2, 2021

The insurance company notified Guardian Claims Department that they are missing the hospital intake form. Guardian Claims Department contacted the client regarding this.

September 8, 2021

Client sent Guardian Claims Department the intake form, which was then forwarded to the insurance company.

September 10, 2021

The insurance company confirmed receipt of the intake form.

September 13, 2021

Claim is processed and applied towards client deductible.

Total Amount Applied Towards Annual Deductible: $2,867 USD

Total claim processing time: 26 days

Scenario 5: Reimbursement for Chiropractor Expenses

June 24, 2021

Client emailed Guardian Claims Department the necessary documents to submit the claim, which included a medical report from the traumatologist stating the start date of the symptoms, the treatment plan, the cost per session, and the payment receipt per session

June 24, 2021

Guardian Claims Department forwarded those documents to the insurance company.

July 7 2021

The insurance company replied confirming the receipt of all documents.

July 14, 2021

The insurance company reimbursed the client directly for the expenses.

Total Amount Reimbursed to Client: $52.50 USD per session

Total claim processing time: 20 days

Scenario 6: Reimbursement for Post-Surgery Rehab

June 01, 2021

Client emailed Guardian Claims Department the necessary documents to submit the claim, which included medical report indicating the procedure that was performed and the reason why they needed rehab, the cost per session, treatment plan and payment receipts.

June 01, 2021

Guardian Claims Department forwarded those documents to the insurance company.

June 8 2021

The insurance company replied confirming the receipt of all documents.

July 01, 2021

The insurance company reimbursed the client directly for the expenses.

Total Amount Reimbursed to Client: $249.82 USD

Total claim processing time: 30 days