Request Time Frames and Statuses
On the Dashboard, in the Funding Portal, select HRA tab then select Activity tab to view expenses.The Activity page lists the participant’s reimbursement requests and applicable details (e.g., request status). Select the "Receipts" tab to locate used and unused participant receipts. The participant can only see receipts uploaded and located in the Used Receipts section.
When a participant mails in or faxes a document and the document is linked to the participant's account, a "Document Received" line item in the Account Updates section displays along with details of when the document was received.
Faxed Reimbursement Requests:
If the participant faxed their documentation but we have no record of it after the above timeframes have lapsed ask the following questions:
Mailed Reimbursement Requests:
If the participant mailed their documentation but we have no record of the request after the above timeframes have lapsed ask the following questions:
Submission by mail or fax not received within this time frame, the Funding Department and OFR 2s are not able to further assist in finding the submission. If the participant has faxed in documentation with a barcode please request them to wait 48 hours before proceeding with resubmitting their request; if this is necessary please encourage the participant to submit their request online if possible. If the participant has mailed their request and it included their personalized barcoded form please encourage them to wait five days before resubmitting their request.
If the participant has not used a barcoded form or has not used their own form please assist them with requesting their own form and educate them about the benefits of submitting their request through the Mobile App or online. Advise the participant to wait an additional 48 hours for their previously submitted request to be manually entered.
If the participant is adamant they have sent the request twice and we have no record of their submission submit a QA JIRA ticket by following the template in the Troubleshooting Faxes document.
| Reimbursement Request Time frames |
| Request Method | Shows in Funding Portal | Receipt Status |
| Submitted Online/Mobile | Upon Submission | Displays in Used Receipts - allow 1 business day to display |
| Faxed | When processed by claims | Displays as an unused receipt within 4 hours |
| Mailed | When processed by claims | Displays as an unused receipt within 4 hours of scanning received mail (allow up to 10 days mail time) |
When a participant mails in or faxes a document and the document is linked to the participant's account, a "Document Received" line item in the Account Updates section displays along with details of when the document was received.
Remember:If a participant does not send the reimbursement request to the fax number on the form, the above time frames do not apply.
Faxed Reimbursement Requests:
If the participant faxed their documentation but we have no record of it after the above timeframes have lapsed ask the following questions:
- Did you use a barcoded form? Was it your own form? (If it was not barcoded their form has to be manually entered; if they did not use their own form this may cause difficultly locating the correct account and will require manual entry)
- Have you made multiple copies of the form you have faxed? (If they have made multiple copies this will diminish the quality of the barcode and the form over time)
- Did you receive a transmission successful/Fax OK notice?
Mailed Reimbursement Requests:
If the participant mailed their documentation but we have no record of the request after the above timeframes have lapsed ask the following questions:
- Did you use the barcoded form? Was it your own form? (If it was not barcoded their form has to be manually entered; if they did not use their own form this may cause difficultly locating the correct account)
- When did you mail the form (We need to allow for up to 10 days mail time)
- Do you have the address of where you sent the request? (Compare this address to the address listed for the participant in the funding portal)
Submission by mail or fax not received within this time frame, the Funding Department and OFR 2s are not able to further assist in finding the submission. If the participant has faxed in documentation with a barcode please request them to wait 48 hours before proceeding with resubmitting their request; if this is necessary please encourage the participant to submit their request online if possible. If the participant has mailed their request and it included their personalized barcoded form please encourage them to wait five days before resubmitting their request.
If the participant has not used a barcoded form or has not used their own form please assist them with requesting their own form and educate them about the benefits of submitting their request through the Mobile App or online. Advise the participant to wait an additional 48 hours for their previously submitted request to be manually entered.
If the participant is adamant they have sent the request twice and we have no record of their submission submit a QA JIRA ticket by following the template in the Troubleshooting Faxes document.
Cancelling/Voiding a Paid or On Hold Expense
If a participant wishes to cancel or void an expense, which was processed and paid, representatives need to inform them of the expectations of receiving an overpayment. The same information is required if the participant wants to cancel an expense that is on hold, and not paid. In this situation, there is not an overpayment possibility, as the payment was not processed.
In order to process their request, a Pega case must be transferred to the Funding Team with the following details:
In order to process their request, a Pega case must be transferred to the Funding Team with the following details:
- Participant Name
- Primary CID
- Expense ID
- Amount/Monthly Claim Amount
- Date of Service/Date of service range for requested denial (Example: 1/1/2020-3/31/2020)
- Reason for Denial/Cancel
- What action is needed
Note:The Funding Team case should be resolved within 5 business days.
Statuses
| Expenses |
Approved: Expense approved, and payment not sent.
- The Expected Payment Date is the date the participant can expect payment. If the participant receives the reimbursement via check, include anticipated mail time.
- If the payment is delayed (Two days after expected payment date) or expected date changes after the original due date, check if the invalid flag is present. Go back to the Participant Search screen and select "Details" to see the profile page or select the invalid address pop up when logging into the funding portal. If yes, update the address in the SSC and funding portal, inform the participant the check will release within five business days.
- Escalate if there is no invalid address flag and the payment is delayed, create a Funding case. For further information please also refer to the Address Changes document.
- Create a Funding case if the payment is in the Approved status for at least five business days, and there is no Expected Payment Date displayed.
Not Approved: Expenses need additional documentation for review/approval.
- Not approved expenses due to insufficient documentation, the participant may attach new documents to the existing request online (this is the preferred method) or send back their Explanation of Unpaid Expenses (EOUE) along with the updated documentation
- For mail or fax, print a cover sheet from the Funding Portal, provide the Expense Line ID on a manual cover sheet, or write it on the documents, and fax/mail additional documents (i.e. EOB) to add to the existing request
- We do not recommend participants submit a new request for reimbursement as the original expense will remain in a Not Approved state in the Funding Portal
Partially Approved: A portion of expenses was approved and the other portion was denied / not approved.
- Participants may send several expenses on the same request where the full expense was not approved. Under certain circumstances, the portion was denied or not approved.
- Recurring requests will display as Partially Paid until the last month is paid.
Denied: Not actionable by a participant (ineligible, duplicates, etc.).
- Review the Denied Reimbursement Troubleshooting speed sheet for a denied expense. If the reimbursement request is valid, help the participant fix the issue which caused the denial
- Representatives may be able to submit a Pega case to another team to resolve
Under Review/QA Pending (Five business days or less): This request was processed, and is undergoing a Quality Review to confirm the request has processed correctly. The status on the Activity Detail page displays approved, not approved or denied when the HRA tab reflects Under Review. Review reimbursement request form to ensure:
- It is filled out correctly
- The request is for an eligible expense
- Required documentation is attached
- Direct deposit is set up (encourage set up as necessary)
It can take up to six business days this status to change. If it has been longer than six business days, create a Funding Team Case and inform the participant their request will process within the next three business days.
| Payment |
Processing Payment: Funds subtracted from the contribution; however, payment was not released.
- If status is at processing payment for more than 3 business days for a daily pay cycle and 7 business days for a weekly pay cycle (to find the pay cycle, go back to "return to participant list", manually search the CID in the Employee Code field and click on "details" on the right hand side. Scroll down to the middle of the page), create a Funding Team case
- ACH payments may take up to two-days before showing deposited. During these two days, the account shows as processing payment
Payment Sent: Payment has been sent to the participant but has not yet been cashed or received.
- If the participant has direct deposit, the payment should arrive within three business days once the request is in Payment Sent status.
- If they do not have direct deposit, the participant will receive a paper check for this request. A mailed check can take up to ten calendar days to arrive.
Partial Payment Sent: A portion of the payment was sent to the participant and was not cashed or received.
Paid: The check cashed, or the direct deposit sent.
Processing Scheduled: A recurring premium expense is paid out on a future date.
On Hold: Expense was approved and is waiting to move to Processing Payment.
If there is an available balance in the account participants may see these messages:
- We reviewed your reimbursement request and have approved this expense. However, we are evaluating if used to offset a previous overpayment. If the money is not used to offset an overpayment, your payment will process on the next scheduled payment date
- If there is no overpayment on the account, the payment will process on the next scheduled payment date.
- See Processing Payment for instructions on time frames
- Your reimbursement request was approved. However, payment is not processed until you update your mailing address online
- Verify if the address is correct in the Funding Portal and update as necessary. Suggest setting up Direct Deposit to ensure payment is received if there are concerns with their address
- If there is no address concern and the status does not change after seven business days, create a Funding Team case
- We reviewed your reimbursement request and have approved this expense. However, you do not have an available balance for that plan year. Plan rules restrict money from your current plan year used to pay for expenses that occured in another plan year
- The client does NOT allow rollback, and a participant has an approved expense for a prior year and no available balance from the same plan year
- This could apply with or without an available balance
- We reviewed your reimbursement request and have approved this expense. It is on hold as it was submitted in advance for services not yet incurred or it is awaiting payment processing
- This is for an AR file received before the start of the plan year. It meets all the criteria for payment. However, as the plan year has not started, it is on hold until the start of the plan year
- We reviewed your reimbursement request and have approved this expense. However, you do not have enough funds in your reimbursement account for this expense
- For monthly contributions, this status may display pending the receipt of the next contribution
- If the client allows rollback, it will be paid with the next annual contribution
- We reviewed your reimbursement request and approved this expense. However, there is no available balance for that plan year. Plan rules restrict money from your current plan year, used to pay for expenses that occured in another plan year.
- The client does NOT allow rollback, and a participant has an approved expense for a prior year and no available balance from the same plan year
- This could apply with or without an available balance
Note:A portion of the expense may be paid with the balance On Hold if the payment has depleted available funds.
Cancelled: Voided payments. Below are possible situations this status may occur:
- Returned Mail / Invalid Address: Voided check indicates not delivered by postal service. Check if the address is invalid in the funding portal. If yes, update the address in the SSC and funding portal, making sure to follow the Address Change instruction resource. The check releases within five business days. If the participant’s address is correct in the SSC and funding portal, however, the invalid address section is marked Yes, remove the Invalid Address indicator per the Address Changes document and save the record.
- Participant returned the check resulting in a voided line because they did not want reimbursement for the expense
- Checks older than 18 months and voided as part of post-conversion cleanup or the bi-annual check process where funds returned to the participant's account
- Advise the participant that setting up direct deposit helps to prevent this issue in the future
Bank Account Required: Expenses approved. However, if there is no direct deposit setup, it can not be paid. This is required by OPERS and effective 6/1/2020 the State of Rhode Island will also require Direct Deposit be setup.
Void Processing: A reissue of an outstanding check was requested and is processing.
- Allow four business days for reissue of a new check. If longer than four business days, create a Funding Team case
- For checks over 16 months old, the check is voided, and funds return to the participant's account
| Overpayment |
Overpayment: The expense was originally paid. However, it was reprocessed into an overpayment status.
Used for Offset: The expense was approved, but the expense is being used to resolve an overpayment for an ineligible expense.
- By selecting Overview under the HRA tab, you can see the total amount used for Offset each year
- Go to the specific plan year and select Show More and the Expense Used for Offset section shows the total amount for the selected year
Partially Paid: The expense was approved, but a portion of it was used for offset.
Recovered: The expense was in overpayment, but it is resolved.