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In most cases, Thrizer is able to complete an automatic out-of-network (OON) benefit check and return an estimate for a client.
When an automatic check does not work, it usually means the insurance plan was unable to return complete benefit information in real time. This does not mean the client lacks out-of-network coverage.
Below are the most common reasons this occurs, listed in order of frequency.
This is the most frequent cause of a failed automatic benefit check.
Even small discrepancies can prevent an insurance plan from finding a client’s coverage, including:
If the information does not exactly match what the insurer has on file, the plan may not return eligibility or benefit details.
Some plans respond to eligibility requests but do not return all the information needed to calculate OON benefits.
Commonly missing fields include:
When required data is missing, Thrizer cannot provide a reliable estimate without additional verification.
Some insurance plans are unable to return OON benefit details through real-time eligibility systems.
In these cases, the plan may:
This behavior is determined by the insurance plan’s systems, not Thrizer.
Certain insurance plans require benefits to be verified by phone, particularly for out-of-network mental health services.
When this is required, automated benefit checks are not available.
If a client has recently:
Their benefits may not yet be available across all insurance systems.
Some plans separate medical and behavioral health benefits across different administrators.
In these cases, an eligibility response may include medical coverage but omit mental health benefit details.
A small number of plans allow out-of-network claims but do not expose OON benefit details through digital eligibility systems.
When this occurs, automated checks are limited even though claims may still be submitted.
If an automatic OON benefit check does not work, Thrizer may need to verify benefits manually or confirm details directly with the insurance plan before providing an estimate.
This process helps ensure that any benefit information shared with the client is accurate and reliable.
Automatic benefit checks provide estimates based on information returned by insurance plans. Final reimbursement amounts are always determined by the insurer after claims are processed.
