Claims & Billing Policy

1. Overview

Cari provides comprehensive billing and claims management features for healthcare providers. This policy outlines our commitments regarding claims processing, reimbursement, and dispute resolution.

2. Claims Processing

2.1 Electronic Claims Submission

Our Platform supports electronic submission of insurance claims to major payers, including:

• Primary and secondary insurance claims
• Workers' compensation claims
• Government programs (Medicare, Medicaid where applicable)
• International insurance providers

2.2 Processing Times

Claims are typically processed within the following timeframes:

• Clean Claims: 7-14 business days
• Claims Requiring Additional Information: 14-30 business days
• Complex Claims: 30-45 business days

These timeframes are estimates and may vary based on the specific payer and claim complexity.

2.3 Claims Requirements

To ensure timely processing, all claims must include:

• Complete patient demographic information
• Valid insurance/payer information
• Accurate diagnosis codes (ICD-10)
• Procedure codes (CPT, HCPCS)
• Provider NPI and billing information
• Supporting documentation as required

3. Reimbursement

3.1 Payment Processing

Once claims are adjudicated by payers, reimbursement is processed according to the payment terms of each specific payer. Funds are deposited directly into the provider's designated bank account.

3.2 Payer Reimbursement Rates

Reimbursement rates are determined by the insurance payer, not by Cari. We cannot guarantee specific reimbursement amounts and recommend verifying payer fee schedules independently.

3.3 Patient Payments

The Platform supports collection of patient responsibilities including copays, coinsurance, and deductibles through multiple payment methods:

• Credit and debit cards
• Bank transfers
• Mobile money (in supported regions)
• Payment plans

4. Claim Denials

4.1 Common Denial Reasons

Common reasons for claim denials include:

• Missing or invalid patient information
• Invalid insurance eligibility
• Services not covered under the patient's plan
• Missing or incorrect coding
• Timely filing deadlines exceeded
• Duplicate submissions
• Requires prior authorization

4.2 Denial Management Tools

Our Platform provides tools to:

• Identify denial patterns and trends
• Receive alerts for denied claims
• Access denial reason codes and descriptions
• Generate appeal documents
• Track appeal status

5. Dispute Resolution

5.1 Internal Review Process

If you believe a claim has been incorrectly denied or processed, you may initiate a dispute through:

• Dashboard: Navigate to the specific claim and click "Dispute"
• Support Ticket: Contact our billing support team
• Phone: Call our billing support line

5.2 Dispute Timeline

• Initial Review: 3-5 business days
• Additional Information Request: Notified within 5 business days
• Resolution: Typically 14-21 business days
• Final Decision: Communicated in writing

5.3 Appealing Denials

When filing an appeal:

• Include the original claim number and denial reason
• Provide supporting documentation
• Include a clear explanation of why the claim should be paid
• Submit within the payer's appeal deadline (typically 30-90 days)

6. Refund Policy

6.1 Provider Refunds

If a payer requests a refund (追回) of previously paid claims, the provider is responsible for repaying the amount. Our Platform will notify you of any refund requests and may deduct amounts from future payments.

6.2 Patient Refunds

If a patient has been overcharged, refunds are processed within 5-7 business days through the original payment method.

7. Fee Schedule

7.1 Platform Fees

Cari charges the following fees for claims processing:

• Electronic Claims Submission: Included in subscription
• Paper Claims Conversion: $0.50 per claim
• Secondary Claims: Included
• Claim Resubmission: Included (first 3 attempts)
• Additional Resubmissions: $0.25 per claim

7.2 Transaction Fees

• Credit Card Processing: 2.9% + $0.30 per transaction
• ACH/Bank Transfer: 1% (max $10)
• Mobile Money: 2% per transaction

8. Reporting & Analytics

The Platform provides comprehensive reporting including:

• Claims submission and payment reports
• Denial analysis and trends
• Revenue cycle metrics
• Payer mix analysis
• Collections effectiveness
• Custom report builder

9. Support

Our billing support team is available to assist with:

• Claims submission questions
• Denial assistance and appeals
• Payment reconciliation
• Technical issues
• Training on billing features

10. Contact Information