Overview
Yuzu attempts to pay claims as soon as possible. There are a number of reasons why this is not always possible. The goal of this guide is to understand claim statuses and be able to diagnose the reason a claim has not been paid yet.
How a claim gets paid: A claim is adjudicated. If it's approved, its payment goes into a bundle for the group. The bundle is released, and the provider is paid, once funding is in place.
Relevant claim statuses:
“In processing”: Not yet adjudicated
"Pending": Approved but not released
Turnaround times are tracked by Yuzu and are available as part of the “Turnaround Times” report. These do not track timelines after payment release for ACH vs. checks but more details on this are included below.
Group funding
The bundle draws on the group's claims fund. If the fund balance is lower than what the bundle needs, Yuzu can't release it. Group funding details for when and how groups are funded or invoiced is on the “Invoices” tab.
Stop loss funding
Aggregate filing pending with the carrier: Before claims can be paid, money must be sent by the carrier. When a filing has been waiting more than 14 days, the claim page shows "Aging stop-loss filing … still awaiting reimbursement from the carrier."
Specific / High-dollar claim review filing: Claims may wait until the filing is paid. If a high-cost claimant review is denied, the claims are denied.
Carrier has paid the filing but the claim is not released: Money may already be committed to the claims that were filed, so this claim remains unpaid. The page shows "Open stop-loss filing … the carrier has already reimbursed it."
Other reasons a claim isn't paid yet
Claim held for manual review: Claim was not auto-adjudicated and needs to be reviewed manually. This could be due to dollar threshold, claim complexity or pre-cert review. More details on pre-cert reviews here: https://yuzu.health/docs/guides/prior-authorizations-what-to-know
COBRA premium unpaid (Yuzu-managed COBRA only): the claim is held until payment arrives or the grace period ends. If the grace period has already expired, the coverage is pending termination.
Timelines after payment release
ACH: If the provider is paid through ACH, which can be viewed on “Communications” and “Pay” tab of the claim, they should receive payment in 24-48 hours. Providers are encouraged to sign up for ACH because there is no associated fees, faster turnarounds, and greater auditability into payments
Checks: Yuzu prints and mails the check through a vendor on the day the payment is released. The expected delivery date is about 8 days after release. A user can see the check status and the expected delivery date on the claim's "Pay" and "Communications" tabs, and in the remittances page of the provider portal.
A small number of checks are not cashed after 90 days. These are usually checks that were lost, sent to an old address, or not deposited. If a provider says a check did not arrive, confirm the pay-to address on the claim first. Then open a case so Yuzu can cancel the check and send a new payment. Switching to ACH avoids these delays.