Overview
Alma’s role in your provider’s practice is to manage the administrative work that comes with taking insurance, which includes running eligibility checks on your insurance policies and filing claims on your provider’s behalf.
This article gives an overview of Alma’s claims process, so that you have visibility into how we estimate insurance costs and create invoices for sessions with your provider.
How Alma’s claims cycle works
Step 1: Eligibility Checks
When either you or your provider enters your insurance details in the Alma portal, we will confirm with your health plan that your policy is active and in-network with Alma’s Insurance Program. We’ll also
After we’ve notified you and your provider of this initial estimate, we will continue to re-verify your benefits with your health plan periodically. You can read more about our eligibility verification process here: How Alma Conducts Eligibility Checks.
Step 2: Invoicing and Payments
After your appointment, your provider will submit an insurance claim to the Alma portal. Based on the details your provider shares, we will:
- Submit the claim to your health plan for processing;
- Pay your provider their rate for the session; and
- Invoice you for your payment responsibility based on our eligibility checks (for copays) or your EOB (for coinsurance).
Please note: If your payment responsibility type is a copay, you’ll receive an invoice shortly after your session. If your payment responsibility type is coinsurance, you’ll receive an invoice after your claim is processed by your health plan. This typically takes 45-60 days after your provider submits the claim for your appointment.
Having a credit card enrolled in Autopay on the Alma platform saves you the hassle of tracking invoices and worrying about timely payment. With Autopay, when we invoice you for your Alma sessions, our system will charge the card you have on file within 24 hours. This also ensures that your provider is paid promptly for their services.
Step 3: Claim Processing
Once we have submitted your provider’s claim to your health plan, it generally takes 45-60 days for your plan to review the details of the claim and determine the final cost for the session. Note that health plans can also reprocess claims weeks or months after the initial processing if they identify an error in their internal processes after the fact.
Once your health plan completes its review of the claim, they will send you an Explanation of Benefits (EOB), which details how they have applied your insurance benefits to Alma sessions. Review this resource for tips on how to understand your EOB.
- If you see an error in your EOB, call the number on the back of your insurance card to request a review. For guidance on what to have on hand when you call your health plan, read: Contacting Your Insurance Carrier.
Step 4: Cost Adjustments (If Necessary)
In the vast majority of cases, your health plan’s EOB will confirm Alma’s initial cost estimate. However, there may be cases where the health plan either denies a claim or determines a different client payment responsibility than we initially quoted. Since this is determined by your health plan and not by Alma, we are only able to relay information that we have access to at the time of the eligibility check.
If your invoice has already been paid and your processed claim shows a lower cost than what you were initially quoted, Alma will refund the amount overpaid to your original payment method. We will also update your eligibility check on record to match the amount the claim returned, so that future invoices are accurate.
If your processed claim shows a higher cost than you were initially quoted, Alma will issue a new invoice for the outstanding amount. We will also update your eligibility check in the portal to mitigate future invoice adjustments.
- If you are enrolled in Autopay, Alma will charge the card we have on file when we issue the new invoice. You will be notified 10 days in advance of any charges taking place via Autopay.
- If you are not enrolled in Autopay, we will email you the updated invoice to pay manually using a credit or debit card.
- You will have 60 days to complete payment of their invoices. We will send weekly reminders of outstanding balances.
If the claim is denied, Alma will reach out to you and your provider to explain why the claim was rejected, as well as offering options for revising and resubmitting the claim.
If you would like to split payments across set increments, you can reach out to us by clicking the Help button in the bottom right corner of the Support Center to request a payment plan.
If you believe that there was a processing error in how your claims were processed, please reach out to your health plan at the number on the back of your insurance card to request a review.
Navigating Invoice Adjustments
Your insurance company ultimately decides what you owe for each visit, which means that the cost we quote you for every visit is an estimate and may be subject to change after the claim processes.
When you encounter eligibility or claims issues with your mental health care coverage, taking prompt action can help resolve problems efficiently. Your first step is to review your insurance policy to understand coverage details and review your Explanation of Benefits. The amount on your Explanation of Benefits (EOB) from your insurance should match the amount Alma invoices you. If you disagree with your EOB, you may appeal this decision by calling the number on the back of your insurance card and speaking to the Claims Department.
Immediate Action Steps:
- Contact your insurance company to request a detailed explanation of any denial or error, documenting the representative's name, call reference number, and explanation provided.
- Reach out to Alma's Support Center to share what you discussed with your insurance company
- If you contact your insurance company, please ask for the call reference number and share this with Alma as this can help us quickly reconcile any eligibility or claims issues.
Step 5: The Option to Appeal
Once a claim has returned to Alma with the final payment responsibility confirmed by your insurance plan, if you disagree with the payment responsibility for the claim you may appeal this decision with your insurance plan. Because the insurance carrier determines the exact payment responsibility you owe as stated in the Explanation of Benefits (EOB), Alma is unable to assist in the claims appeal process.
To appeal a claim, you will need to contact your health plan, usually via the phone number listed on the back of your insurance card. Typically, your health plan will provide an appeal form for the provider to fill out.
You may need to have the following information available in order to begin the appeal process:
- Relevant medical records
- Session notes
- Prior authorization documentation if applicable
- An explanation/cover letter stating the reason for appeal
- Anything else that may help explain:
- Why the session was needed
- Why specific CPT codes and diagnostic codes were chosen
The appeal process varies between various insurance payers. Once you contact your health plan, they will share any additional details on how to appeal and what to expect.
Frequently Asked Questions
What determines the final cost that you owe for a session?
All patients will receive an Explanation of Benefits (EOB) document from their insurance company for every visit they have with their provider. This document provides the relevant information regarding how each claim was processed, including the payment amount you are responsible for. This resource provides additional context on how to read your EOB.
Why does my payment responsibility type (copay or coinsurance) determine when I am invoiced?
At Alma, we strive to ensure that your invoicing experience is reliable, accurate, and aligned with industry standards and payer requirements - whether you owe a copay or coinsurance. If you owe coinsurance, receiving your invoice after a claim is processed by your health plan reduces the risk of invoice adjustments and helps to ensure that the amount you are charged is accurate and matches your EOB.
How do you access your Explanation of Benefits (EOB)?
Explanations of Benefits are notifications from your insurance company on how they processed a claim. These can be sent through paper mail as well as electronically.
If you are having trouble locating your EOB document for a particular date of service, you may call the number on the back of your insurance card and request an EOB to be reissued to you.
Please note: Many insurance companies now offer digital EOBs if you create an account via their online portal.
Why might your EOB show a different amount than your initial estimate from Alma?
Alma works to provide the most accurate assessment of your payment responsibility upfront. However, as mentioned in the initial eligibility email you receive, your quoted cost is an estimate based on the information that your insurance company has shared with Alma at the time of your visit.
Given that there can be many complexities in how insurance plans are structured, your insurance company may process your claim with a different cost. Your insurance company is the ultimate decision-maker when it comes to the cost that you owe for each visit.
If your insurance carrier processes your claim and confirms a different payment responsibility than what was initially anticipated, Alma cannot change the amount your EOB states you owe. If you have any concerns about how a claim was processed, you will need to reach out to your insurance company directly.
What does Alma do to support the accuracy of eligibility checks?
In order to minimize these types of discrepancies, our team takes the following actions:
- Our team conducts eligibility checks ahead of the first session of every month to ensure that changes to your benefits are accounted for. This is dependent on the information available at the time of the eligibility check.
- If a claim is processed differently than your initial estimate, we will notify you and your provider and update your eligibility check to match your processed claims.
- We are in constant communication with our payer partners to ensure that we have access to the most up-to-date information regarding client eligibility.
What if your EOB says that your claim was processed out of network by mistake?
Please contact your insurance company and let them know that your claim processed out of network in error and ask for it to be reprocessed. The best person to get a claim reprocessed is the patient! For guidelines on how to speak to your health plan, review: Contacting Your Insurance Carrier.
If needed, you can also submit a copy of your EOB to our Support team by clicking the Help button in the bottom right corner of the Support Center.
When can you expect to receive a refund if you are overcharged?
As soon as the claim returns to Alma from your insurance company, you will receive an email from Alma notifying you that your invoice has either been updated or canceled based on what your insurance says you owe.
You will also receive an email confirming you’ve been refunded. From there, the refund should be applied to the original payment method within 14 business days. Please note that it can take 45-60 days for the insurance carrier to process the claim and confirm the correct payment responsibility.
What if you are unable to pay the additional amount you were invoiced?
Our team can provide a payment plan to help minimize the financial impact of these scenarios. If you would like to sign up for a payment plan, please reach out by clicking the Help button in the bottom right corner of the Support Center. We'll be happy to assist you.