Step 1: Visiting a Healthcare Provider Within Your Employer Health Plan
Employees enrolled in employer-sponsored plans through Allied Benefit begin the claims process the moment they receive care. When services are rendered by in-network providers, the provider usually submits the claim directly to Allied Benefit Systems.
If the provider is out-of-network or does not file on behalf of the patient, employees may need to collect itemized receipts and manually submit a claim via the Allied Benefit member portal.
Step 2: Claim Submission via Allied Benefit Systems Portal
Manual claim submission requires accurate documentation, including the provider’s name, tax ID number, dates of service, and CPT or diagnosis codes. Supporting documents such as referral forms or pre-authorizations (if required) should also be uploaded.
Claims can be submitted online through the secure Allied Benefit portal, which provides step-by-step guidance and real-time status updates.
Step 3: How Allied Benefit Processes the Claim
Once the claim is received, Allied Benefit Systems adjudicates the claim based on:
- Your plan’s coverage details
- Whether services are medically necessary
- Provider’s in-network status
- Applicable deductibles, co-pays, or co-insurance
Claim review typically takes 7 to 14 business days. During this period, employees can log into their member dashboard to track updates or request clarification.
For employers managing multiple plans, plan administration tools are also available through Allied.
Step 4: Explanation of Benefits (EOB) and What It Means
After processing, an Explanation of Benefits (EOB) is generated. This document details the amount billed by the provider, the portion paid by Allied Benefit, and any patient responsibility.
Understanding the EOB is crucial to avoid confusion between the summary and an actual bill. If the claim was only partially covered, reasons will be outlined clearly.
Step 5: Filing an Appeal If a Claim Is Denied
In case of denial, employees can initiate an appeal using the claims portal. Common reasons for denial include services not covered by the plan, lack of prior authorization, or missing information.
To appeal:
- Review the EOB for the denial reason
- Gather relevant documents (provider letters, medical records)
- Submit an appeal request through the Allied Benefit Systems appeals process
Appeals must typically be filed within 180 days of receiving the denial.
Step 6: Final Payment or Reimbursement
Once the appeal is reviewed or the original claim is approved, payments are processed. In-network providers receive payments directly. For out-of-network services, employees may be reimbursed. Direct deposit is an available option via the Allied portal.
Keeping track of all correspondence and documents ensures smoother resolution in future claims.
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