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Frequently Asked Questions
Does Symetra credential or evaluate Third Party Administrators? If so, what is the criteria and frequency of the credentialing process?​

Yes, Symetra issues a standard TPA questionnaire which is updated annually for E&O (Errors and Omissions) and general liability coverage.

What is your average time to settle Specific and/or Aggregate claims? Most claims are processed in less than 5 business days. On-site Aggregate claims are settled immediately after the audit is complete.
What information do you require to process a Specific claim? An Aggregate claim? Please refer to our Administrative Guide
Do you require an audit of large hospital bills?
No.
If hospital audits are performed, does Symetra pay for them? If the claimant is over the Specific deductible, we will reimburse the fee if they are based on savings of up to 30 percent. 
What type of proof of payment is required for Specific and Aggregate claims?
Specific claims use reports with the paid date; however, we do verify receipt of payments with providers. For Aggregate claims we refer to bank statements, check registers or ledgers.
What is your definition of a “paid claim?" 




A “paid claim” means that a) the covered expense is adjudicated according to the terms of the employee benefit plan, b) a check is written and mailed, or electronically deposited directly to the payee within the policy period, and c) funds are available to honor the check. To ensure funds are available, they must be deposited no later than the first working day following the end of the policy period.
How do you handle large claims where the group cannot fund the entire amount?
We offer advanced funding as long as covered expenses up to the Specific deductible meet our definition of a paid claim. Please see our Administrative Guide for more information on these requirements.
How are advanced funded claims handled? Do you reimburse, then conduct an audit? What is the turnaround time?
Advanced fund claims are audited prior to reimbursement within the 5-day  turnaround goal. Symetra will accommodate rush requests when notified at time of claim submission.
How do you provide reimbursement once a claim exceeds the Specific deductible?
Reimbursement checks are mailed to the TPA submitting the claim unless otherwise requested in writing by the policyholder. We also offer electronic funds transfer (EFT).

To what extent is Symetra amending their stop loss policies due to the ACA, including the external review process and IROs?

 

 

 

 

 

Symetra’s policies are designed to follow the eligibility and eligible expense criteria of the employer’s benefit plan. This design helps eliminate gaps between what plans will pay for and what we will reimburse.

No changes have been made to our stop loss policies as a result of the ACA, the external review process, or IROs. However, the following statement will be included on the Schedule Page of each policy:
“Claims determined to be eligible under the Employee Benefit Plan in final and binding external review by independent review organizations (IROs) will also be deemed Covered Expenses under the Policy. Claim exception requests pending and under IRO review at the end of the Policy Period will continue to be considered for coverage.”

What is Symetra’s position with respect to determinations made by IROs?

Claims determined to be eligible under the plan in final and binding external review by IROs will also be deemed eligible under our stop loss policy.

If a claim goes to external review, and an IRO decides that the claim is valid, will Symetra honor that determination?

Yes.

 

Does Symetra have to approve the IROs that plan sponsors elect to utilize?

No.

 

 

 

 

 

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