Till we have only learned a plan types, how they formed, operating and regulating under federal (ERISA & ACA) and state laws. But in this lesson, we will discuss top insurance companies who offer these plans and serve people with or without profit. Note, there are many private insurance companies but the listed below are the largest and many small insurance companies operating under them:
- Blue Cross Blue Shield (BCBS)
- United Healthcare (UHC)
- Aetna
- Cigna
- Humana
- WellCare (Meridian)
Before starting, let's explore another term IPA plans and TPA Plans
IPA plans
IPA stands for Independent Providers Association or often called Independent Practitioners Association. In IPA, different providers and health care professionals come together to make a large group of providers like association plans and better negotiate rates with insurance company for providing quality of care. However, each provider within the same IPA is independent and can run his / her own facility but under the IPA contractor.
Think of it like a bridge between insurance companies and independent providers. Mean, providers remain independent (they don't work for a hospital) but they gain access to patients through their insurance company's contract.
How does it work?
- The insurance company signs a contract with an IPA for their HMO or sometimes for Medicare Advantage (we will cover this in the Medicare chapter) members.
- An IPA manages a network of providers, including PCPs and specialists. Patients enrolled in that health plan must choose a PCP within the same IPA for referrals and care coordination. Patients cannot see doctors outside the IPA, except in emergencies.
- IPAs are usually paid a capitation fee (a fixed amount per patient per month) by the insurer, and then they distribute payments to providers. All claims are processed under the IPA, and IPAs are often based on specific geographic areas.
- Role of IPA and eligibility: Billers must verify whether a patient’s plan uses an IPA. If it does, then they must check if the provider is part of the IPA’s network. If the provider is not in the IPA network for that plan, the insurance company will deny the claim because the provider is considered out of network.
In short:
IPA = a network of independent doctors that contracts with insurers.
How it works: The IPA handles contracts, referrals, and payments, while doctors remain independent.
Role in eligibility: Billing staff must check IPA assignment so claims won’t be denied for being “out of network.”
Provider must have licensed, and his / her facility should be within the IPA area to enroll.
TPA Plans
A TPA stands for Third Party Administrator. TPA plan refers to a self-funded health insurance arrangement in which an employer takes on the financial risk of paying employees’ healthcare claims, while a third-party administrator (TPA) manages all the administrative functions of the plan. The TPA serves as the operational hub, connecting the employer, employees, and the stop-loss insurance carrier.
How TPA Plans Work?
In a self-funded health plan, the employer pays for employees’ healthcare costs directly instead of paying fixed premiums to an insurance company. This gives the employer more control over how healthcare money is spent. To handle the daily operations of the plan, the employer hires a Third-Party Administrator (TPA). The TPA takes care of tasks like processing and paying claims, managing provider networks so employees can see doctors and hospitals, making sure the plan follows federal and state rules (like ERISA, ACA, HIPAA), and helping employees with questions and benefit information.
To protect against catastrophic or unusually high claims, employers purchase stop-loss coverage. This coverage helps to reimburse the employer if medical cost exceeds maximum limits set by employer while the TPA works with the stop-loss carrier to coordinate reimbursement accordingly.
Benefits of TPA Plans
Cost Control & Transparency: Employers see exactly how healthcare dollars are spent and can adjust plan design.
Flexibility: Plans can be customized to employee needs, unlike standardized fully insured plans.
Expert Support: TPAs manage the complex administrative tasks, freeing employers from day-to-day operations.
Key Points to Remember:
Not Insurers: TPAs do not take on the financial risk — they only manage the plan. The employer funds the plan, and large unexpected claims are covered by stop-loss insurance.
Bridge Role: TPAs connect all parties — ensuring employees get access to care, employers maintain control, and stop-loss carriers protect against large claims.
In short, TPA plans are self-funded employer health plans where the employer pays claims, the TPA runs the administration, and stop-loss insurance provides financial protection.
What is a Stop-Loss Carrier?
A stop-loss carrier is an insurance company that sells stop-loss insurance to self-funded employers. In a self-funded plan, the employer pays employees’ medical claims directly instead of paying premiums to an insurance company. That can save money but also creates risk, what if one employee has a $1 million claim?
To protect against that kind of financial shock, employers buy stop-loss insurance. The insurer providing this protection is called the stop-loss carrier. Also note that stop loss coverage is not health insurance, it's type of financial protection for employers. Employer can sets maximum limits (threshold) while purchasing plans and stop loss carrier pay rest of all the amount that exceeds the threshold.
How Stop-Loss Works
There are two main types of protection an employer can buy:
- Specific (Individual) Stop-Loss
Protects against very large claims from a single employee. (it works at the individual level)
Example: Employer pays the first $50,000 of an employee’s care. Anything above that is reimbursed by the stop-loss carrier. - Aggregate Stop-Loss
Protects against high overall claims for the whole group of employees. (it works at the group level)
Example: Employer sets an annual claims budget of $2 million. If total claims exceed that, the stop-loss carrier pays the rest.
Role in a TPA Plan
- The employer funds the plan and pays normal claims.
- The TPA manages claims and plan operations.
- The stop-loss carrier reimburses the employer if claims exceed the agreed-upon thresholds.
- Together, this setup gives employers cost control with a safety net in case of catastrophic or unusually high claims.
In short, a stop-loss carrier is the insurance company that provides financial protection to self-funded employers. It doesn’t insure employees directly — it insures the employer against excessive claim costs.
Note, like self-insured employers, Medicaid also hires TPAs for managing its claims at state level.
As previously we learn, Railroad Medicare & Tricare has Contractors who manages administrative tasks similar to TPA plans we learn here, so what is the difference between contractors & TPA?
Both contractors and Third-Party Administrators (TPAs) act as outside entities that help manage healthcare programs, but they operate differently. Contractors are usually federal-level administrators. For example, in Medicare, the government assigns one contractor to a specific state or region, and that contractor manages claims, payments, and rules for that area. Since each contractor is assigned by CMS (Centers for Medicare & Medicaid Services), the rules and services they manage can differ by state or region. For instance, a Medicare contractor in Illinois may cover certain services differently than a contractor in Texas. Contractors generally have longer contracts (about 5–7 years) and only one contractor is assigned per region or state.
On the other hand, TPAs typically operate at the state or employer level. They are used by self-insured employers and state Medicaid programs to process claims and administer benefits. Unlike federal contractors, multiple TPAs can operate in the same state, and their rules are usually more standardized across different regions. TPAs usually work under shorter contracts (about 1–5 years) and they coordinate directly with insurers or state Medicaid programs.
In short:- Contractors = Federal-level administrators (Medicare, Military Insurance, Railroad Medicare programs runs at federal level), one per region, rules may vary, contracts last 5–7 years.
- TPAs = State/employer-level administrators (Medicaid, self-insured employers runs at state level), multiple can operate in one state, rules more standardized, contracts last 1–5 years.
What is the Group No. and Member ID?
It's important to understand these terms, as in our billing journey we will be bother with these numbers and IDs:
A Group Number identifies a specific employer-sponsored insurance plan, while a Member ID is a unique identifier for the individual insured under that plan. The group number groups all policies under the same employer, and the member ID distinguishes the individual within that group for claims and billing purposes.
Group Number
Purpose: To identify the employer's specific health insurance plan.
Application: Only used for employer-based or group plans (AHP, ESI, HCSM, family plans (ACA & non-ACA)), not for individual policies (ACA individual plans & other individual plans)
Function: Allows insurance carriers uses these group no. to track records for specific plan's billing and benefits.
Member ID
Purpose: A unique identifier for the individual policyholder or insured person.
Application: Used on health insurance cards to distinguish you from other members of the same plan.
Function: Necessary for providers to identify the insured person and process claims correctly
Note, if person purchases individual plan (ACA or non-ACA), only Member ID issued to individual while group no. only issue if person enrolled in group plan with Member ID for distinguish employee / person from other members of the group plan.
Blue Cross Blue Shield Association (BCBSA)
Blue Cross Blue Shield (BCBS) is not a single insurance company. Instead, it’s a federation of 33 independent health insurance companies that operate under the BCBS Association (BCBSA) brand. Together, they form the largest health insurance network in the U.S. and collectively employ over 150,000 people nationwide, which makes BCBS one of the top 20 largest employers in the U.S. Each local BCBS company operates in a specific region (statewide or multi-state). By 2022, BCBS provided health insurance coverage to more than 115 million people.
Example: Blue Cross Blue Shield of Illinois, Anthem Blue Cross (California), and Horizon BCBS (New Jersey) are all separate companies, but each is part of the BCBS system.
- Anthem Blue Cross Blue Shield (for-profit) operates in:
- California (Anthem Blue Cross)
- Colorado
- Connecticut
- Georgia
- Indiana
- Kentucky
- Maine
- Missouri
- Nevada
- New Hampshire
- New York (Empire BCBS in parts of NY)
- Ohio
- Virginia
- Wisconsin
- Horizon Blue Cross Blue Shield
- New Jersey
- Health Care Service Corporation, HCSC
- Illinois
- Montana
- New Mexico
- Oklahoma
- Texas
- Independence Blue Cross
- Pennsylvania (Philadelphia region)
- Highmark Blue Cross Blue Shield
- Pennsylvania (outside Philly region)
- Delaware
- West Virginia
- Premera Blue Cross
- Alaska
- Washington State
- Regence Blue Cross Blue Shield
- Idaho
- Oregon
- Utah
- Washington
- CareFirst Blue Cross Blue Shield
- Maryland
- Washington, D.C.
- Northern Virginia
- Blue Shield of California (separate from Anthem Blue Cross in CA)
- California
- Florida Blue (BCBS of Florida)
- Florida
- Empire Blue Cross Blue Shield
- New York (Downstate NY, including NYC & surrounding areas — Anthem brand)
- Excellus Blue Cross Blue Shield
- New York (Upstate regions)
- Blue Cross Blue Shield of Michigan
- Michigan
- Blue Cross Blue Shield of Massachusetts
- Massachusetts
- Blue Cross Blue Shield of North Carolina
- North Carolina
- Blue Cross and Blue Shield of Kansas
- Kansas
- Blue Cross and Blue Shield of Nebraska
- Nebraska
- Blue Cross Blue Shield of Arizona
- Arizona
- Blue Cross Blue Shield of Rhode Island
- Rhode Island
- Blue Cross Blue Shield of Vermont
- Vermont
- Blue Cross and Blue Shield of Louisiana
- Louisiana
- Blue Cross Blue Shield of Alabama
- Alabama
- Arkansas Blue Cross Blue Shield
- Arkansas
- Blue Cross and Blue Shield of Mississippi
- Mississippi
- Blue Cross and Blue Shield of North Dakota
- North Dakota
- Blue Cross and Blue Shield of Minnesota
- Minnesota
- Blue Cross Blue Shield of South Carolina
- South Carolina
- Blue Cross and Blue Shield of Tennessee
- Tennessee
- Blue Cross of Idaho (A separate company from Regence Blue Cross Blue Shield of Idaho).
- Idaho
- Blue Cross Blue Shield of Wyoming
- Wyoming
- Capital Blue Cross
- Operates in the Harrisburg region and Lehigh Valley of Pennsylvania, and is distinct from Independence Blue Cross and Highmark.
- Blue Cross Blue Shield of Hawaii
- Hawaii
- Wellmark Blue Cross and Blue Shield
- Iowa
- South Dakota
In short:
There are 33 independent BCBS companies nationwide. Some (like Anthem or HCSC) operate in multiple states, while others (like Horizon in NJ or Florida Blue in FL) are state-specific.
How BCBS works & Benefits?
- Local Independence: Each BCBS company is locally operated, but licensed by the national BCBS Association.
- Network Sharing: Through the BlueCard program, members can use doctors and hospitals nationwide that participate in any BCBS network — even if their “home plan” is in another state. e.g. if you have BCBS BlueCard Plan of Illinois as your local insurer (buy coverage BCBS Illinois) and travel to Florida and see a doctor in the BCBS Network (at Florida), your plan still works services through your Illinois BlueCard (The insurance card that BCBS issue to their members as coverage prove called a BlueCard). This makes BCBS a Local + Nationwide reaching organization.
Note: For billing point of view, we have to send the claim to BCBS Illinois as local BCBS company to get reimbursement not to Florida, otherwise claim will be denied with "coverage denied due to network limitations, please submit new claim to local BCBS to get reimbursement".
- Huge Network: Accepted by ~90% of doctors and hospitals in the U.S.
- Nonprofit/For-profit Mix: Some BCBS companies are nonprofits, while others (like Anthem) are for-profit.
In short, BCBS is a nationwide network of independent health insurers under one brand. Each local BCBS company serves its state/region, but members enjoy a broad provider network across the country.
BCBS Plan Types
BCBS offer all major forms of coverage, such as:
- Employer-sponsored group insurance
- Individual ACA marketplace plans
- Medicare Advantage, Medicare Supplement (Medigap), and Part D (we will discuss late)
- Medicaid (in some states)
- Short-term and Indemnity Plans
- Directly plans purchases
As Blue Cross Blue Shield offers many plan “brands” under its 33 independent companies. These names often describe special programs, government contracts, or specific product lines. Here’s a list of the most popular and widely recognized BCBS plan names across the U.S.:
- BlueCard® Program
Through this plan, BCBS members can go to any BCBS contracted doctor in any state and coverage will be provided by BCBS. (Suitable for traveler)
BlueCard Programs are BCBS Commercial PPO plans that allow members to see any provider or hospital (under BCBS network) nationwide.
- Blue Cross Community Health Plans (BCCHP)
These are the Medicaid Managed Care Plan (specially operating in Illinois and some other states). Only Medicaid eligible individual can get this plan. BCBS acts as a TPA for Medicaid.
- Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)
The individual who are qualify for both Medicare & Medicaid often called a Dual eligible program BCBS provides both coverages into one plan.
- Blue Cross and Blue Shield Federal Employee Program (FEP)
The Blue Cross and Blue Shield Federal Employee Program (FEP) is a health insurance plan offered by Blue Cross and Blue Shield within the Federal Employees Health Benefits (FEHB) Program for federal employees, retirees, and their families, both in the U.S. and overseas. However, under this plan BCBS offers three main plan options: Standard Option, Basic Option, and FEP Blue Focus.
- Blue Advantage / Blue Advantage Plus
Medicare Advantage plans (Part C) offered by Blue Cross Blue Shield (BCBS) companies. These plans combine hospital (Part A) and medical (Part B) coverage, and often include prescription drug (Part D) coverage and other extra benefits. The specific coverage and benefits can vary based on the state and the specific plan you choose. BCBS provides two options under plan e.g. Blue Advantage & Blue Advantage Plus
- Blue Choice® / Blue Choice Preferred
These are lower-cost PPO or HMO network options within BCBS, Normally for those members who choosing affordable in-network options.
- Blue Essential / Essential Blue
BCBS give options for ACA marketplace or Medicaid options through these plans but they varies by state. Similar to above, these are low cost ACA coverage plans for individuals and families.
- Blue Secure / Blue Medicare Rx
These known as Medicare products coverage i.e.
- Blue Secure = Medicare Advantage plan
- Blue Medicare Rx = Medicare Part D prescription drug plan
- BlueCard Worldwide®
BlueCard Worldwide was a program from BCBS that provided medical care and claim supports to members travelling or living outside their U.S. service area.
- Special Programs
- Blue Distinction® – recognizes top hospitals and doctors for quality care.
- Blue 365® – member discount program for wellness, fitness, and health products.
BCBS Insurance Card:
BCBS Member ID format
Normally, BCBS ID starts with 3 alpha prefixes followed by 6 to 14 numbers or letters or both which makes BCBS ID 9 to 17 digits long. However, some IDs like FED (federal employee program, stand-alone vision, dental & pharmacy plans) has slightly different format. So BCBS IDs may be looks like below:
- ABC1234567
- ABC1234H567
- ABCD1234H567
- ABCD1234H56789012
Note: BCBS first 3 alpha prefixes shows type of plan and they very state by state mean ZXY in Illinois not equal to ZXY in Texas. However for complete prefixes list click here.
For complete guide on how these ID and BCBS cards formats looks like click here.
Here are some known ID formats for specific plans
XOG - any ID starts with XOG are BCBS Community Plan in Illinois R - Any ID starts with R followed by numbers are BCBS Federal Employee Program
Aetna
Aetna is one of the largest health insurance companies in U.S. founded in 1853 and based in Hartford, Connecticut. However, in 2018, it was acquired by CVS health, so now it operates as part of a larger healthcare group.
Aetna sells and administers many types of health insurance and related benefits. Instead of being a federation of independent companies (like BCBS), Aetna is one national company operating under the CVS Health umbrella.
Aetna Insurance Card
Aetna Member ID Format
Standard Format Normally, an Aetna ID starts with a letter (commonly “W”) followed by 9 to 11 digits. Example: W123456789-00 Medicare Advantage Format For Medicare Advantage plans, Aetna uses a 12-digit numeric ID that always begins with “10.” Example: 104537953814 Suffix (Last Two Digits) The last two digits of an Aetna ID represent a suffix that identifies the covered member under a family policy. This differentiates the primary policyholder from dependents: 00 → Primary policyholder (subscriber) Example: W123456789-00 01 → Spouse Example: W123456789-01 02, 03, 04, etc. → Dependent children, assigned in sequence Example: W123456789-02, W123456789-03
In short:
Aetna is a national health insurance company (owned by CVS Health) that provides coverage through employers, the ACA Marketplace, Medicare, Medicaid, and specialty plans. It’s a major player in the U.S. insurance market, known for its integration with CVS pharmacies and its strong Medicare Advantage and prescription drug offerings.
Cigna
Cigna is a global health services company, not just a U.S. health insurer, Cigna operate on more than 30 Countries worldwide. Headquarter founded in Bloomfield, Connecticut. It was founded in 1982 from the merger of Connecticut General (CG) and INA Corporation (Insurance Company of North America) into one Cigna.
Similarly Aetna and BCBS, Cigna also called a biggest health insurance network in U.S. as well as other worldwide countries. Health coverages are same with brand names changed like Cigna PPO, Cigna Choice Plue PPO
Cigna program called Health spring is Medicaid Managed Care Plan that provides coverages to Medicaid eligible individuals and Cigna act as TPA to Medicaid.
Cigna Insurance Card
Cigna Member ID format
Standard Format (Commercial & Marketplace) A Cigna member ID is typically 9 to 10 characters and can be alphanumeric (mix of letters and numbers). Example: U12345678 or 123456789 Often starts with a letter "U" for commercial plans, while Marketplace plans may be purely numeric. Medicare Advantage & Part D (PDP) IDs are usually 11–12 digits, sometimes with a mix of numbers and letters. Example: 12345678901A Suffix (Last Two Digits or Letters) Like Aetna, suffixes are used to identify dependents under the same family policy. Common pattern: 00 → Primary subscriber (policyholder) 01 → Spouse 02, 03, etc. → Dependent children in sequence Example: U123456789-00 (subscriber), U123456789-01 (spouse), U123456789-02 (child)
Humana
Humana is a largest U.S. based health insurance company headquartered in Louisville, Kentucky. It was founded in 1961 (originally a nursing home company, then expanded into hospitals, and later into insurance). Humana is a single national company, Unlike BCBS, Aetna & Cigna, Humana specifically focused on Medicare Advantage & Part D plans which makes Humana biggest Medicare Centered Insurer with some other ACA and commercial plans approach. Also Humana Better Health is one of the program Humana offers as Medicaid Managed Care Plans for Medicaid eligible individuals.
Humana Insurance Card
Humana Member ID format
Commercial / Employer Plans IDs are usually 9 digits numeric. Example: 123456789 For family coverage, suffixes are used, just like Aetna and Cigna. Medicare Advantage and Part D Typically 11 characters alphanumeric, often starting with H. Example: H1234567890 Cards clearly say Medicare Advantage (Humana Gold Plus, PPO, etc.). Medicaid (Humana Better Health) ID formats vary by state rules, often alphanumeric or state-specific numeric sequences.
In short:
Humana is a national health insurance company best known for its Medicare Advantage and Part D plans. While it does offer some employer and Medicaid plans, its biggest strength is providing healthcare and wellness services for seniors, making it a top choice in the Medicare market.
United Healthcare (UHC)
UnitedHealthcare (UHC) is the largest health insurance company in the U.S., alongside BCBS, Aetna, Cigna, and Humana. It is part of UnitedHealth Group, a Fortune 5 company headquartered in Minnetonka, Minnesota. UnitedHealthcare Corporation was founded in 1977 to purchase Charter Med and create a network-based health plan for seniors. It became a publicly traded company in 1984 and changed its name to UnitedHealth Group in 1998.
Two Main Divisions of UnitedHealth Group (UHG):
- UnitedHealthcare (UHC): Health insurance company (commercial, Medicare Advantage Plans, Medicaid Managed Care Plans, ACA exchange).
- Optum: Health services division (pharmacy benefit management, data analytics, provider services, and a clearinghouse that helps providers submit claims electronically and checks for errors).
Structure of UHC:
Unlike BCBS (which is a federation of 33 independent companies), UHC is one centralized national company operating under a single corporate structure.
Affiliates & Subsidiaries Connected to UHC:
- UMR → Third-party administrator (TPA) for self-funded employer health plans.
- USHEALTH Group → Offers fixed indemnity, short-term, and supplemental plans (more consumer-driven).
- Oxford Health Plans → UHC’s brand in NY/NJ/CT region.
- AARP Medicare / AARP Plans (by UHC) → Offers supplementary plans for Medicare (act as secondary insurance for both Medicare and Private Insurance Companies)
- Savier Health (often called “UHC Savier”) → Cost-containment partner that helps manage claims, negotiate bills, and reduce provider payment errors.
UHC Insurance Card
Normally, each subsidiaries has their own insurance card formats but below one is standard UHC insurance card:
UHG ID Formats
UHC and its affiliated and subsidiary partners has their own ID formats. Normally, UHC ID digit 9 to 12 numeric digits i.e. 123456789, CO followed with numbers for Savier health, UMR IDs are 8-12 digits alphanumeric or pure numeric i.e. 72413674, etc.
Standard UnitedHealthcare (UHC) Commercial / Employer Plans: Format: 9 numeric digits Example: 123456789 Sometimes followed by a suffix (-00, -01) for dependents. Marketplace (ACA Exchange) Plans: Format: 9–12 alphanumeric Example: AB123456789 Medicare Advantage: Format: 11 alphanumeric characters Example: 1A234567890 Always shows Medicare Advantage on the card. Medicaid (Community Plan): Format: Varies by state → alpha + numeric (e.g., M12345678) or 9 digits. Card shows Community Plan + state Medicaid logo. UMR (UHC’s TPA) Format: 8–12 characters Can be all numeric or alphanumeric. Example: 72413674 or 76X1234567 Savier Health (cost-containment partner) Savier-linked IDs often begin with a prefix like CO followed by numbers. Example: CO1234567 These IDs appear when Savier is managing claims on behalf of UHC/UMR. Vice versa.
Meridian
Meridian is a Medicaid-focused (Medicaid Managed Care Plan) health insurance company, was founded in 1997 in Michigan and later expanded to other states. In 2018 Meridian was acquired by WellCare, and then in 2020, WellCare became part of Centene Corporation (one of the largest Medicaid insurers (MCO) in the U.S.) so now Meridian is part of Centene Corporation. Meridian focuses almost entirely on low-income populations and has strong community providers network in Michigan and Illinois.
Plans offered by Meridian
- Medicaid Managed Care
- Meridian mainly provides coverage for people eligible for Medicaid.
- Operates in Illinois and Michigan as
Meridian Health Plan.
- Medicare-Medicaid Plans (Duals / MMAI)
- Offers special plans for people eligible for both Medicare and Medicaid.
- Marketplace (ACA) Plans
- In some states, Meridian also offers Marketplace/Exchange plans under Centene’s umbrella.
In short:
Meridian is a regional health insurance company that mainly serves Medicaid members in Michigan and Illinois. It’s now part of Centene Corporation and focuses on Medicaid, dual-eligible (Medicare + Medicaid) plans, and some Marketplace coverage.
Whereas WellCare provides wider health coverage options including Medicare Advantage, Part D plans, Medicaid Managed Care Plans (in many states), ACA market plans.
Frequently Asked Questions
What is Timely Filing Limits (TFL) for these Insurance Companies?
Normally, TFL depends on the specific plan type and design. Generally, Aetna provides 120 days for commercial plan claims and 180 days to one year for ESI and Medicare Advantage plan claims. Similarly, Cigna and UHC allow 90 days for in-network and 180 days for out-of-network providers to file a claim from the date of service. However, Cigna Medicaid Managed Care Plan (Cigna HealthSpring) has a 120-day limit. Humana has a TFL of 90 to 180 days for general plans, while Medicare Advantage plan claims allow up to one year. Likewise, Meridian allows one year, and WellCare allows 180 days from the date of service.
What is Timeframe for these insurance companies to process claims?
Under ERISA and State insurance laws, most clean claims are processed (paid or denied) within 30 to 45 days from date insurance company received claim, However, claims for Medicare Advantage and Medicaid Managed Care plans are process faster typically takes 14 to 30 days. Claim processing time depends on claim complexity and method of submission like if claim is submitted through clearinghouse electronically having no errors (like simply office visit), insurance companies auto adjudicate claim within 24 to 72 hours and processed claim while if claim is submitted through paper or have errors or mistakes or need manual reviews, documentations, may lead claim to be processed from 60 to 90 days or even more delay.
Does these insurance be a secondary?
Yes, all of these private insurances provide both secondary as well as primary coverage. However, AARP mostly provides coverage as secondary.
Does these insurance companies make PR and what if coverage lost?
Yes, most of these insurance companies makes PR while processing claims, and also if coverage terminated, then all cost is patient responsibility unless provider has a contract with insurance company not to do balance billing if coverage drops.
What is Commercial Plans?
Commercial plans are health insurance coverages provided by private insurance companies. They can be offered through Employer-Sponsored Insurance (ESI), purchased on the ACA Marketplace, or bought directly from the insurer. All of these types (HMO, PPO, EPO, POS, HDHP, etc. that we covered earlier) are considered commercial plans if provided through private insurance companies.
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