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Participant Advocacy Service

Willis Towers Watson can help alleviate your burden by assisting your participants with issues relating to their claims.

Participant advocacy is an important yet time-consuming task for many employers. Willis Towers Watson can help alleviate your burden by assisting your participants with issues relating to their claims. While our work in this area varies somewhat from client to client based on your needs and vendors, our services are outlined below.

Participant advocacy

Participant advocacy services are designed to assist plan participants with issues related to denied or incorrectly processed claims. Participant advocacy includes:

  • Providing a specialized and welltrained group within the servicecenter to handle benefit claims and coverage issues (beyond eligibilityrelated issues)
  • Creating and managing a case through completion when participants believe they have a claim after contacting the health care provider
  • Contacting the health care provider to gather information and initiate research
  • Initiating immediate calls and discussions with providers for critical issues (e.g., participant denied service at provider/pharmacy) to ensure service is provided
  • Instructing the participant on appropriate procedures when a claim payment issue exists and an appeal is in order
  • Explaining a health plan’s response to the participant
  • Assisting the participant in understanding health plan requests for further claim-related information
  • Maintaining a current list of contacts at each carrier for critical and noncritical issues
  • Maintaining participant confidentiality throughout the process
  • Obtaining release from participant to divulge confidential data as needed
  • Monitoring and following through with a case, once created, until resolution
  • Providing periodic reports of activity

Advocacy staffing

Our advocates are a specially trained group of customer service representatives (CSRs) who handle the most complex issues that participants cannot resolve on their own. The CSRs are required to have a deep knowledge of health plans and the claim adjudication process, and be able to effectively identify and communicate trends as part of their role. Whereas our mainline CSRs provide information, process transactions and help participants navigate Willis Towers Watson’s self-service systems, our advocacy CSRs work on behalf of customers across multiple entities to drive resolution of more complex issues.

Participant advocacy service summary

Participant advocacy service summary
Activity Standard service Participant Advocacy service
Educating your participants on your business rules and plan provisions for health plans administered by Willis Towers Watson
Performing initial research to rule out administrative and/or eligibility-related causes for a claim payment being denied
Coordinating warm transfers and three-way calls with carriers, providers and other third parties to assist in issue resolution
Resolving a health claims issue by contacting the health insurance carrier and/or provider on behalf of the participant when an issue with a denied claim has been reported
Processing manual enrollments at the health insurance carrier for urgent situations to ensure service is provided
Educating participants on the steps for filing an appeal with a health insurance carrier
Monitoring and following up on the status of an escalated claim payment issue, through resolution
Providing client with eligibility-related data pertinent to a claims appeal, upon request
Educating the participant when a claim payment was appropriately denied
Storing claims-related correspondence and documentation in Willis Towers Watson’s administration system
Providing quarterly reporting of advocacy activity for trend analysis
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Participant Advocacy Service PDF .4 MB
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