Real claims scenarios
Scenario 1: Pre-Authorization of a Medical Procedure - Direct Payment to Medical Facility
- 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).
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.
-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.).
Client submitted MRI and medical report, but it was missing a doctor signature and some other information, so we requested that from the client
Client sent the complete medical report with doctor signature and missing info.
With all information submitted, the insurance company sent the Guarantee of Payment Letter.
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
- 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.
Guardian Claims Department submitted the documents to insurance company.
The insurance company replied confirming receipt of the documents.
The insurance company emailed Guardian Claims Department asking for the client’s bank info to make reimbursement payment.
Guardian Claims Department sent client bank info to the insurance company
The insurance company reimbursed total amount of preventive checkup expenses to client.
Scenario 3: Reimbursement to Client for Prescription Medication after Meeting Deductible
Guardian Claims Department received the medical report, doctor prescription and the payment receipt from the client.
Guardian Claims Department sent the documents to the insurance company.
The insurance company replied confirming receipt of the documents.
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
Guardian Claims Department sent that documentation to the insurance company.
The insurance company confirmed receipt of the documents.
The insurance company notified Guardian Claims Department that they are missing the hospital intake form. Guardian Claims Department contacted the client regarding this.
Client sent Guardian Claims Department the intake form, which was then forwarded to the insurance company.
The insurance company confirmed receipt of the intake form.
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
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
Guardian Claims Department forwarded those documents to the insurance company.
The insurance company replied confirming the receipt of all documents.
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
Guardian Claims Department forwarded those documents to the insurance company.
The insurance company replied confirming the receipt of all documents.
The insurance company reimbursed the client directly for the expenses.
Total Amount Reimbursed to Client: $249.82 USD
Total claim processing time: 30 days