Payment and Claims

There are numerous components at play in the enablement and function of the deductible awareness and out of pocket checking and claim submission features. This chart is not meant to be fully representative, but to include some of the main components. For further in depth information see each individual section below.

Value	Definition	Use
Contracted Rate	The amount that can be charged to an insurance plan for a visit.	See below; used in Eligibility File (EF), AMT, claim. Commonly represents fair market value (FMV). Must be designated for both PPO and HSA plan (subscription) types. Follow-up visit types should have contractedRate value = $0
Coinsurance Percentage	The percentage of the healthcare cost a patient pays after they have fulfilled their deductible.	Applies to HSA plan/subscription types.
Expected Cost	The cost a patient is expected to pay for a visit without taking into account whether they have met a deductible or reached their out of pocket max for the year.	For HSA plans, expectedCost = contractedRate (except when CARES Act waiver applies - then = $0. For non-HSA plans, expectedCost = Copay. Displayed on the following screens in the app: Onboarding match screen Manage Subscription screen Pre visit bot script
Sponsor	A commercial customer commonly referred to as the Employer within the database. This is the entity that has a contract with Transcarent.	Represented in the AMT.
CARES Act - Consolidated Appropriations Act, 2023 (abbreviated as CAA, 2023)	The CARES Act is an initiative to help provide healthcare-related and economic aid in the wake of COVID-19. One aspect of the CARES act is that it allows virtual care costs that apply to HSA deductibles to be $0 to a patient, regardless of the visit reason.	Related to the Waiver field in the AMT and EF.
Claim	Electronic Data Interchange file (EDI) 837 file submitted to health plans (insurance carriers) to denote the encounter between a provider and patient.
Change Healthcare (CHC)	Third party vendor that fetches remaining deductible and out of pocket maximum (OOPM) values, and then manages claim submissions to health plans.	CHC supplies crucial information (such as the PayerID).
Charge Amount (Patient Paid)	The dollar amount charged via Stripe to a patient’s payment method (matches the correct participant-level cost share).
Claim Amount	Values sent outbound in the EDI 837 claim related to patient charge and total charge.	HSA: Claim.total_charge_amount and Claim.charge_amount = Contracted Rate Claim.patient_paid_amount = Contracted Rate after going through any calculations using deductible, OOP Max, and Coinsurance % PPO: Claim.total_charge_amount and Claim.charge_amount = Contracted Rate Claim.patient_paid_amount = Copay after going through any calculations OOP max