For many benefits, members can submit claims for reimbursement. Admins can approve, partially approve, request more information, or deny in full.
How to review claims
Review permissions
Tier-two agents, partner admins, and partner super admins can review claims. To learn more, check out “Create and manage partner administrator accounts.”
Go to the Claims tab.
Open the appropriate claim.
Select Start Reviewing. (This lets other admins know that someone is working on this claim.)
Review claim details to ensure the expense is eligible and aligns with plan rules.
Select Approve, Deny, or Needs Information
Disclaimer
First Dollar will not be responsible for any liability associated with any act, omission, or claims decision undertaken by the Admin.
Decision communications
Members will be notified of claim decisions, unless notifications have been disabled based on partnership agreements.
Approving claims
After selecting Approve, you'll choose between the full amount or entering a partial amount for approval. Approval decisions are final; a member will have to submit a new claim for any additional requested amount.
About partial approvals
Unavailable from bulk review
Partial approvals is only available after opening an individual claim and then selecting “Start Reviewing.” It is not available when selecting claims in bulk from the Claims dashboard.
When approving a claim partially, you’ll enter the amount that is approved and select a denial reason for the remaining unapproved amount. The selected denial reason will be shared with the member.
Line-by-line approval
You can only approve or deny an amount; you cannot approve or deny per line item.
Denial reason | Member-facing copy |
Dependent not covered for this expense | Dependent not covered: [$amount] — this dependent isn’t eligible for this expense under your [benefit account type]. |
Expense amount does not match receipt | Amount mismatch: [$amount] — claimed amount does not match your receipt. |
Ineligible expense | Ineligible expense: [$amount] — not covered by your [benefit account type]. |
Other | Other: [$amount] - [admin’s input text]. |
Multiple denial reasons
You can only select one denial reason. If multiple reasons apply, select the primary reason and document the others in the Additional Details section.
Requesting more information
You can also request additional information from the member. The member will receive a claim update with the information you’ve requested to be updated.
Denying claims in full
After selecting Deny in full, select an appropriate denial reason to be shared with the member.
Potential claims denial reasons
Date of expense does not match receipt
Member no longer eligible
Expense incurred outside of plan year
Expense amount does not match receipt
Ineligible expense
Receipt not provided or invalid
Other
Partial Approvals
To partially deny a claim, use the partial approval process that is available after selecting Approve from a selected claim.
Member claim details
Members will see an update on the claim status, approved amounts, denial reasons, and more after admin decisions to approve in full, approve partially, request more information, or deny the claim in full.
Appealing denied claims
Members can appeal denied claims or partially approved claims for the denied amount. To understand the claim appeal process, check out “Appeal a denied claim.”
Plan and member details
To review plan details, select the plan name next to Benefit in Claim Details. Here, you can answer questions like:
Plan Details: Does the plan have an extension period? A receipt requirement?
Eligible Expenses: What categories of expenses are considered eligible?
Merchant Category Code: Where will the card be accepted?
To review member information, select the member’s name next to Member in Claim Details.
Review claims by member
You can also review claims by member. To access this view, go to the member’s page, choose the appropriate benefit, and then select Claims History.
Claims activity
To review claim history and internal notes, scroll to the Activity tab of the claim.
Understanding the claims dashboard
The claims dashboard shows claims by unresolved or resolved status.
Sorting tools
To quickly find the appropriate claim, sort by submission date, status, organization, and benefit.
Unresolved and resolved
You and your team will likely spend most of your time working in the Unresolved tab, where you can review submitted claims. The Resolved tab is where you can see all approved and denied claims.
Claims snapshot
The unresolved claims snapshot gives you a quick overview of your team's progress and workload, as the view filters unresolved claims by status and their time in the queue.
Claim statuses
Status | Tab | Meaning |
New | Unresolved | Unopened new claim |
Updated | Unresolved | Claim resubmitted with requested info |
In Review | Unresolved | Admin is reviewing the claim |
Information Requested | Unresolved | Admin returned claim to member for additional information. |
Approved | Resolved | Admin has approved claim in full |
Partially Approved | Resolved | Admin has approved claim in part |
Payment Pending | Resolved | Payment process has been initiated |
Paid | Resolved | Payment has been made |
Denied | Resolved | Admin has denied the claim |