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Understanding Transaction and Claim Substantiation

Written by Aimee Reynard
Updated 1 month ago
  • Copay Matching. This allows us to program in your copays to your plan so anytime a member swipes for an amount matching a copay it will auto approve without any need for the member to substantiate on that transaction. 

You can review and update your copays anytime on the Ameriflex Portal under the Copay section of the general group page. 

  • Pharmacy/Over the Counter Transactions. At pharmacies and retail locations, most over the counter and RX transactions will auto substantiate based on inventory coding that merchants have in their system. 

At most large retailers, transactions will go through without any substantiation needed. For example, Walmart transactions that go through on the card should not require any transactions. You can use this store locator to determine if your pharmacy will use this technology. 

  • MyPlanConnect. This is an optional add-on service that can be of additional help in reducing substantiations. What this does is port over any explanation of benefits that are created within the medical carrier websites and makes the substantiation process much faster and easier. 

When the participants swipe their card for a transaction the system will not send anything to the member for 90 days as it attempts to match the transaction with an explanation of benefit. If one matches, the employee does not need to do anything else! If it does not match with an explanation of benefits after 90 days, it will then request that documentation from the member. 

Please note: If any of the above methods is not able to substantiate the transaction, the member will receive an alert that additional documentation is needed. Participants would then submit an itemized receipt, or explanation of benefits, via the Mobile App or Online Portal. 

Depending on your group's substantiation settings, if a member fails to substantiate their transactions it could result in temporary deactivation of the member’s card. 

To view your substantiation selection please check the Ameriflex Portal on the general tab, under “Substantiation.” Option 1 is recommended as we will not deactivate any cards automatically, however the employer can control turning off any cards due to outstanding substantiations if they wish to. 

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