Grow with TPAC.
Contact Us
to Learn How.

* Required




Electronic Submission of Claims

for Traditional Products

  1. WHAT IS ELECTRONIC SUBMISSION OF CLAIMS?
    • This is a form of claim submission done by hospitals, doctors, prescription drug venders and other providers. The applicable provider will electronically transfer an employee or dependent’s claim to the administrator instead of mailing a paper claim. The last few years have seen a significant increase in this type of claim submission.
  2. WHAT IS REQUIRED FOR REIMBURSEMENT OF THESE CHARGES WHEN THE PROVIDER OF SERVICE IS A PRESCRIPTION DRUG VENDER?
    • The Employer must have coverage for their Prescription Drug Card Plan under the stop loss policy.
    • For an aggregate claim, an audit will usually be performed on site. A review of the prescription drug bills will be done as part of the audit. The actual bills from the vender must be available to audit. This includes electronically submitted vender bills.
    • For a specific claim, the prescription drug bills for the individual involved need to be submitted with documentation indicating when the vender was paid for each drug. Documentation of the actual bills, whether submitted by the vender to the administrator via paper claim or electronic claim, must be submitted. In the case of electronically submitted bills, a printout of the vender’s charges needs to be submitted for the specific claim individual. An administrator paid claims report of prescription drug charges is not sufficient documentation as this is not a copy of the prescription drug charges.
  3. WHAT IS REQUIRED FOR REIMBURSMENT OF THESE CHARGES WHEN THE PROVIDER OF SERVICE IS NOT A PRESCRIPTION DRUG VENDER?
    • A copy of the electronically submitted claim. This would include an electronic bill that can be printed in a UB-92/HCFA format or a printed copy of the electronically submitted claim data.