EOB FAQs

What is the Consolidated EOB

The consolidated Explanation of Benefits (EOB) is a document that is sent out through ECHO Health, a third party connected to BeniComp® Advantage (BCA). BCA is a supplemental wellness program to the group medical benefits plan (see FAQ-Employers) and traditionally there are two EOB’s issued to the participants in the plans. One is from the medical benefits provider and one is from BCA. These two EOB’s are sent to the participant separately and on different dates. In order to improve communications to the participants, BCA has partnered with ECHO Health to issue one consolidated EOB, pairing both the base EOB and supplemental EOB into one document.

If one EOB is sent, whose information (TPA or BCA) is on the EOB?

On the face of the EOB, the TPA’s information will be on the top portion and BCA’s will be on the bottom near the BCA Incentive Summary. The employee will need to call their TPA for medical plan inquiries and call BCA for deductible credit inquiries.

What if my TPA does not want to introduce a consolidated EOB?

If the TPA does not use the consolidated EOB method, BCA has no way of reporting the TPA’s claim costs (we just see the BCA info, not the TPA info unless a consolidated platform is in place)

What does the consolidated EOB look like?

SEE EXAMPLE CONSOLIDATED EOB The consolidated EOB is no different from a regular EOB, other than the fact that it includes two different EOB’s in one document (base plan and supplemental wellness plan). The top section is for the base plan and lists the claims incurred and processed per individual. The bottom section is for the BCA program and lists the medical plan deductible, BCA plan deductible, BCA deductible satisfied and the remaining deductible. The participant receives a summary of what has been accumulated in total.

How long does it take BCA to adjudicate the TPA’s claim file?

Once BCA receives the medical claims file, it takes 24 hours to adjudicate the claims using our auto-process system. BCA files are sent to ECHO weekly. Claims received by 2:00 pm EST on Thursday will be included in that week’s file transfer to ECHO.

How can the TPA get connected to ECHO?

  • First, the TPA’s software platform must coincide with ECHO’s platform. ECHO is currently able to process many of the major adjudication platforms (check with TPA to find out if their system is one already approved by ECHO). ECHO is currently able to use Eldorado, FACTS, Trizetto/RIMMS, LuminX, LCS, WLT and GBAS. If both adjudication platforms coincide, the TPA will send a test file to ECHO to ensure the systems work together.
  • When the TPA’s system is other than the approved system, BCA will send the ECHO file format to the TPA. The TPA’s output data extract must match up with the ECHO Extract. ECHO and the TPA work together to achieve desired outcomes.


How often is an EOB sent to my provider?

Whenever payment is assigned and made to the provider, ECHO sends a weekly EOB to the provider along with any payments.

What is the claim flow process?

The TPA sends ECHO the group's medical claims file extract with the funds. ECHO then sends the file to BCA. BCA processes the week's claims for any deductible reimbursements and sends the file with funds back to ECHO by Friday. ECHO merges the processed medical claims and deductible reimbursement claims and sends the merged file to any printing house designated by the primary TPA (such as Emdeon) the next business day. ABF mails the consolidated checks/EOBs to the provider and/or employee depending on the assignment of benefits.

Does the TPA need to adjust their files before it is sent to ABF?

No, the file that the TPA sends to their printer is the same file that is used by BCA/ECHO. There are no different files needed.

How often is the EOB sent out?

There is an EOB that follows every check that is issued. If there are no checks sent out in a month, a monthly EOB showing claims activity will be sent to the employee. If there is a check cut every week, there will be weekly EOB's sent to the participant, and provider when applicable. There is a minimum of one EOB sent once a month to the participant to report claims activity for the month.

What if an employee did not earn any credits? Is there still a consolidated EOB sent from ECHO?

Once a TPA is signed up with BCA/ECHO, all claims during the plan year will go through ECHO. If an employee has not earned BCA credits or received their entire reimbursement by mid-year, medical claims activity continues to be reported on the EOB provided by Echo. ECHO remains involved in the process throughout the plan year.

Who should the TPA make the check out to?

Funding is set up through an ACH account that can be debited by ECHO automatically or with authorization via an ECHO funding request. Typically, claims files are sent when the funds are available.

What is the preferred ACH method?

ECHO can either pull the funds electronically via ACH from the TPA's bank account; or the TPA can push funds to ECHO's bank account. The debit can be set up to fund automatically or with the TPA's authorization, whichever is preferred by the TPA.

Does the consolidated EOB work with Full Premium and Cost Plus BCA plans?

The consolidated EOB can be done for both funding strategies if funding is provided prior to release of the claims files for consolidation.

Who fills out the 1099 Form?

ECHO completes the 1099 forms for claims payments issued through them according to IRS Regulations stating that the responsibility falls on "whoever is the last to pay".

How do employees get ID cards?

BCA ID cards are available upon request through the BCA web portal or customer service. It informs the provider of supplemental deductible coverage and how to contact BCA for additional information. It is separate from the medical ID card.

 

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