Get answers to all your questions about Garner​

Here’s all you need to know to help your employees and administer your benefit

Get answers to all your questions about Garner

Here’s all you need to know to help your employees and administer your benefit

Employer FAQ

Program administration

Each Garner customer is assigned a designated account manager. If you are missing the contact information for your account manager, please email AMmanagement@getgarner.com and we will be happy to connect you.

Engagement and utilization reporting is provided to customers quarterly, approximately 10-15 business days after the close of the quarter. For your most recent copy, contact your account manager.

Garner reduces employer costs while offering a richer medical benefit experience for employees. If you are interested in improving engagement and increasing savings by expanding your program, reach out to your account manager or email AMmanagement@getgarner.com to discuss additional options.

Eligible employees

The Garner program is available to employees and family members who are enrolled in some or all of your health insurance plans that you have elected to pair with Garner. Garner uses information provided in the latest eligibility file received from your designated eligibility vendor or the data that is currently in the Garner eligibility portal.

How Garner qualifies providers

Garner provides access to the most accurate provider performance data in the industry. Our data-driven doctor search tool helps employees find the top 20% of all doctors so they no longer have to guess whether they’re receiving the best care.

Garner independently analyzes the largest claims dataset in the United States to objectively evaluate performance of each doctor in your area. We determine whether each doctor follows best practice guidelines and achieves excellent patient outcomes. The following are considered when making our recommendation for Top Providers:

  • Quality: doctors who follow best practices and whose patients have better outcomes
  • Reviews: doctors with the highest patient satisfaction ratings
  • Cost: doctors who refrain from excessive utilization of wasteful services
  • Distance: doctors within a reasonable distance from members (this will vary based on speciality)

For a doctor near you to be ranked as a Top Provider, they must perform better than their local peers on both quality and total cost of care, as well as have a track record of positive patient reviews.

Resource: For additional information on how doctors are ranked, click here.

  1. Garner combines numerous sources of raw data on provider addresses, phone numbers and specialty certifications, among others. We draw from publicly available sources (e.g., NPPES, CMS), as well as private sources that we acquire through partnerships. Our proprietary algorithms combine the data to get a baseline read on each doctor’s phone number, address, appointment availability and specialty focus.
  2. Next, we use our claims dataset to enrich and validate our provider data. This unique approach enables us to more quickly and accurately identify any issues in our data. Examples of the power of this approach include:
    • We can look at doctors who frequently bill the CPT code 99203 (new patient visit) and have recently stopped doing so. This shows us which doctors have filled their panel and may no longer be accepting new patients. 
    • We can look at doctors who are billing with a new group NPI to check whether they may have moved their practice.
  3. We employ a large team of full-time representatives to verify directory accuracy by phone. We also have built an in-house AI robot that calls physician offices for verification. We prioritize validating directory information based on provider quality.

For simple labs and imaging services, patients sometimes do not need a referral from a doctor. Garner recommends imaging centers to help direct members to cost-efficient providers. The costs for services provided by imaging centers and labs vary dramatically between facilities, though the procedures are standardized and the quality is at parity. 

Before the day of the procedure, members must ensure that they find an eligible facility and ensure the Top Provider who made the referral is added to their account.

CURRENT PCPs AND CONTINUITY OF CARE

If your company has elected to offer employees the option to add their current PCPs to their list of approved providers, the following information may be useful.

If an employee has been seeing a doctor that isn’t a Top Provider since before Garner was offered as a benefit, they may be able to add them to their list of approved providers so that out-of-pocket costs for their services will qualify for reimbursement. To be approved, each doctor must fall into one of these categories:

  • Primary care provider
  • Pediatrician
  • Geriatrician
  • Gynecologist
  • Therapist
  • Psychologist
  • Psychiatrists

To add doctors to a member’s list of approved providers, members should find their doctor’s profile page in the Garner Health app and click “Request approval.” Then, follow the workflow on the app screen. To validate that the doctor is approved, go to “Settings” on the home screen in the app and click “Approved providers” to view the list. Approved providers will appear on this page with the “Added on” date. Out-of-pocket costs incurred from services provided by approved providers will be eligible for reimbursement after the date they were added.

If you are currently being treated for an acute medical condition, such as the examples listed below, and your provider is not a Top Provider, Garner may make an exception and approve your provider until a safe transfer of care to a Top Provider can be arranged. 

Examples of qualifying medical circumstances include:

  • Pregnancy, for the duration of pregnancy and through six weeks post-delivery
  • Newborn care for a child between birth and 36 months
  • Newly diagnosed or relapsed cancer and a patient currently receiving chemotherapy, radiation therapy or reconstruction
  • Transplant candidate or transplant recipient in need of ongoing care
  • Recent major surgery in the acute phase and follow-up period
  • Serious acute condition in active treatment, such as heart attack or stroke
  • Treatment for terminal illness
  • Therapy for substance abuse 

To qualify for a continuity of care exception:

  • Your current provider must be in-network.
  • Your health insurance plan must cover the service provided.
  • Garner’s Concierge must approve the provider based on your medical situation. 

Medical circumstances that arise after the beginning of the first Garner plan year do not qualify for a continuity of care exception.

If you’re in treatment for one of the conditions listed in the answer above, you may qualify for a continuity of care exception. Contact the Concierge to see if you qualify prior to your next visit.

If you feel your circumstance meets the criteria for a continuity of care exception, contact the Concierge to see if you qualify prior to your next visit. And as always, the provider must be in-network, and your health insurance plan must cover the care in order for the related qualifying out-of-pocket medical costs to be eligible for reimbursement.

The Concierge will ask you several questions to understand your unique medical situation. The decision process for these requests can take up to 3 business days after you’ve provided the necessary information to the Concierge. If your continuity of care exception is granted, the Concierge will add the provider to your list of approved providers. Future qualifying out-of-pocket medical costs will be eligible for reimbursement.

If and when there is a break in the care, you may be required to see a Top Provider for future care in order for these out-of-pocket medical costs to qualify for reimbursement by Garner.

Continuity of care exceptions do not apply to medical services or circumstances that can be transferred safely from one provider to another, such as:

  • Routine exams
  • Vaccinations
  • Health assessments
  • Stable chronic conditions
  • Minor illnesses

Medical circumstances that arise after the beginning of the first Garner plan year do not qualify for a continuity of care exception.

Covered Services and circumstances

All services billed or ordered by approved providers qualify for reimbursement.* This includes office visits, lab work, imaging (X-ray and MRIs, among others) and hospital bills incurred during a surgery. When you receive care from doctors who you don’t have the ability to select (e.g., an anesthesiologist for a surgery, a pathologist or a radiologist for an X-ray or an MRI), these doctor’s services will be covered as long as the treatment was ordered by an approved provider and covered by your health insurance plan. Members can go to the “Your benefit” page in the app to see the details of their plan.

*Out-of-pocket medical costs will qualify for reimbursement if:

  • The member has created a Garner account and added the provider to their list of approved providers prior to the date of service. The provider must be in-network and the cost must be covered by your health insurance plan.
  • The type of cost qualifies for reimbursement under your particular Garner plan. Depending on your Garner plan, costs for things like prescription drugs or emergency services may or may not qualify for reimbursement.
  • If your health insurance plan is paired with an HSA, members will need to incur costs greater than the minimum deductible.

All Garner members may find urgent care clinics in the app so that those expenses qualify for reimbursement. Examples include:

  • Urgent care clinics
  • Retail clinics
  • Minute clinics
  • In-network telehealth (e.g., Teladoc, MDLive)

Costs from urgent care clinics qualify for reimbursement after the date the member finds them in the app. Members can also ask the Concierge to find facilities for them.

For clients that offer emergency coverage, costs incurred from ER facilities (including urgent care clinics) qualify for reimbursement regardless of whether the member finds them before the date of service.

Garner covers all non-invasive tests ordered by an approved provider, whether that provider is an approved PCP or specialist. For an invasive test to be covered, the provider performing the test must be an approved provider.

The following tests are examples of tests that are covered when ordered by an approved provider:

  • Imaging
    • Echocardiograms, including stress echocardiogram
    • MRI
    • CT scans
    • X-rays
    • Ultrasounds
    • Bone scans
    • Mammograms
  • Labs
    • Bloodwork
    • Genetic testing
    • Prostate specific antigen tests
    • Pap smears
    • Prenatal testing
  • Other
    • Electrocardiogram (EKG/ECG)
    • Electroencephalogram (EEG)
    • Hearing tests
    • Sleep studies
    • Zio Patch or external heart monitoring

The following tests are examples of tests that are only covered when the provider performing the test is an approved provider:

  • Colonoscopy
  • Endoscopy
  • Biopsy
  • Laparoscopy
  • Hysteroscopy

Common member-related inquiries

Members must be enrolled in a health insurance plan that is paired with Garner, and they must create a Garner account to be eligible for the Garner benefit.

Your members can find a provider two ways:

  1. Sign in through the Garner Health mobile app or website and search doctors by tapping “Find a doctor.” Members can search for providers by name or by the type of care needed. Top Providers have a green badge next to their name and are automatically added to a member’s list of approved providers as soon as they are visible on the screen. If a member wishes to see a doctor who is not a Top Provider, they should contact the Concierge.
  2. Our Concierge can assist members with provider searches. Members can message the Concierge through the Garner Health mobile app, getgarner.com or concierge@getgarner.com. The Concierge is available Monday through Friday from 8:00 a.m. to 8:00 p.m. ET to offer personalized support. The Concierge speaks both English and Spanish.

Each individual doctor needs to be an approved provider for claims related to their services to be reimbursed. This is because doctor performance can vary within the same office, practice, or facility.

If a member receives care from a nurse or physician’s assistant who works at the direction of an approved provider on a member’s list, claims for services rendered by those individuals will be covered. The Concierge team may reach out to confirm the relationship between a nurse/ physician assistant and an approved provider in order to approve a claim. They may also offer to add these providers to the member’s Approve Provider list to make processing future claims more efficient.

We also understand that in some cases, a member may see another provider in an approved provider’s office. There are a few specific situations in which Garner will reimburse that episode of care.

  • Urgent sick visits at PCP and pediatrician offices
  • Obstetricians for prenatal and postnatal visits

We suggest that members always check with Garner to see if the provider they are seeing is an approved provider or if services rendered by the provider would qualify for reimbursement.

Out-of-pocket medical costs will qualify for reimbursement if:

  • The member has created a Garner account and added the provider to their list of approved providers prior to the date of service. The provider must be in-network and the cost must be covered by your health insurance plan.
  • The type of cost qualifies for reimbursement under your particular Garner plan. Depending on your Garner plan, costs for things like prescription drugs or emergency services may or may not qualify for reimbursement.
  • If your health insurance plan is paired with an HSA, members will need to incur costs greater than the minimum deductible.

If you have set up a claims feed for members: 

When your member receives care from an approved provider, they must pay their upfront costs as usual. With your partnership, Garner has set up a feed directly with your health insurance and receives claims on a regular basis.

The feed is a data file that Garner receives from the health plan with the same data that the member would find on their EOB. After your health insurance company processes the claim and sends it to Garner, Garner will reimburse the member’s qualifying out-of-pocket medical costs. Because the speed that billing departments submit claims to your health insurance company can vary, it typically takes 6-8 weeks to receive reimbursement after the service takes place. Your member’s reimbursement check will arrive in a plain white envelope.

While claims are not currently visible in the Garner Health app or website, Garner is introducing new functionality to view paid claims, which will be available by the end of 2024. Members can request a list of their claims by messaging the Concierge through their Garner health account. The Concierge will send the member a list of approved and denied claims, including the denial reasons, in the body of the message.

If your members submits claims manually: 

Members can see an overview of all their claims and check the status of each claim on the “Claims” page in the Garner Health app. Simply click on individual claims for the status. If it indicates that more information is required, the member can contact the Concierge directly to provide further documentation. Members can message the Concierge through the Garner Health mobile app, getgarner.com or concierge@getgarner.com. The Concierge is available Monday through Friday from 8:00 a.m. to 8:00 p.m. ET to offer personalized support. The Concierge speaks both English and Spanish.

Due to HIPAA, the individual member will need to contact the Concierge directly to find out why a claim was denied. Some common reasons for denial include:

  • No account: The member did not create a Garner account before the date of service of the claim.
  • No matching provider: The claim is for a service that was not rendered by or related to a provider that was added to the member’s list of approved providers.
  • Approved provider added after date of service: While the claim is for a service that was rendered by or related to a provider that is on the member’s list of approved providers, the provider was added after the claim’s date of service.

If a member believes that a claim was denied in error, they should message the Concierge through the Garner Health mobile app, getgarner.com, or concierge@getgarner.com.

When a claim is rendered or billed by a provider other than the approved provider, Garner may not be able to automatically match the claim to the approved provider. This may occur for claims for labs, imaging, and other services that are billed at the facility level. It can also occur if the rendering provider is a “related provider,” like a nurse or anesthesiologist who works with the approved provider.

For high-value claims over $500, the Concierge may also ask for substantiating documentation to prove that the claim is related to an approved provider if their name is not on the claim. Such documentation can include:

  • A visit summary, care plan, or scheduling confirmation for the claim that shows the eligible provider’s name on it
  • A bill for an office visit or another service with the eligible provider on the same day as the claim
  • For imaging or labs, an order form for the claim showing that the eligible provider ordered the service
  • Any other documentation that links the eligible provider’s name to the service on the claim

The member can send the documentation as an attachment directly to the Concierge through their account for review.

Regulatory Requirements

Billing and claims funding for “admin only”

Garner charges for two types of fees: 

  • Administrative fees, billed monthly
  • Approved claims funding, debited once a week on Friday

Your monthly administrative fee is calculated by multiplying the number of employees eligible for Garner on the first day of each month by your per-employee per-month (PEPM) rate.

Invoices are generated on the first business day of each month. They are sent on the second business day of each month with an ACH draw initiated. They are settled by the fourth business day.

  • Monthly administrative fees: invoices come with a corresponding excel backup that includes employee names, eligibility periods, plans and coverage tiers.
  • Claims funding: each claim batch will come with an Excel backup that provides the date of service, provider seen and amount for each claim approved. To safeguard PHI, we do not include any member-specific information on these reports.

Billing and claims funding for “admin + claims” clients

You are billed once a month. This bill includes Garner’s administrative fees and any funding required for reimbursements.

Your monthly administrative fee is calculated by multiplying the number of employees eligible for Garner on the first day of each month by your HRA funding per-employee per-month (PEPM) rate.

Invoices are generated on the first business day of each month. They are sent on the second business day of each month with an ACH draw initiated. They are settled by the fourth business day.

An ACH for approved claims is initiated every Friday. The ACH transaction settles on the following Tuesday.

BILLING FAQs FOR ALL GARNER CLIENTS

  • If you use the Garner eligibility portal: You must make any eligibility updates directly in the Garner portal prior to the first day of each month.
  • If you use the eligibility feed: Billing is based on the direct eligibility feed set up with your vendor.

Credits and adjustments can be requested by emailing accountsreceivable@getgarner.com within 30 days of an invoice. All corrections will be reflected as a credit in the following month’s invoice. Changes flagged past 30 days will not be adjusted.

All invoices reflect the full PEPM rate listed in your agreement, regardless of the start and end dates of employees.

Bank information updates can be requested by emailing a new ACH form to accountsreceivable@getgarner.com. 

Invoices and corresponding backups are generated and emailed from accountsreceivable@getgarner.com via QuickBooks.

There is not a centralized location to find prior invoices. You can email accountsreceivable@getgarner.com to request a copy of any prior invoice.

Garner will provide information that is not considered PHI or sensitive PII (SSN, addresses and phone numbers are not provided) if the information is available in your eligibility file.

Garner direct debits your bank account each month to ensure timely claims payments. ACH pushes or checks are not supported.

End-of-year (EOY) settlement (For admin + claims clients only)

If there is a remaining balance in your HRA funding after claims, administrative fees and performance guarantee fees are removed, you will receive a payment that is a fixed percent of that remaining amount as long as you renew your Garner account for the next year.

For a given HRA year, the EOY settlement is calculated as: 

  • EOY settlement pool = HRA funding minus claims paid, administrative fees and performance guarantee fees
  • EOY settlement = a fixed percentage (outlined in your agreement) of the EOY settlement pool

If the EOY settlement pool is less than or equal to $0, the EOY settlement is $0.

Garner will pay your end-of-year settlement for a given HRA year within 15 days of the later of the dates below as long as you remain a Garner client:

  • The date the rebate calculation is complete, which is normally seven months after the deductible reset date
  • 30 days after the beginning of the first renewal period that begins after the end of the relevant HRA year

An ACH credit is initiated and paid into your account.

CLAIMS SUBMISSION DEADLINES

The benefit reset date is when a member’s Garner benefit resets to its full value. Members can find their benefit reset date on the “Your benefit” page of the Garner Health app.

After the benefit reset date, members have 90 days to submit claims for remaining expenses incurred the year prior to that date. This is called a runout period.

For TPA feeds, “submit” means when we receive a claim file.

For manual clients, “submit” is when a member actually submits their claim.

The runout period starts the day after the members’ benefit reset date.

Members have 90 days after the benefit reset date to submit claims for remaining expenses incurred the year prior to that date. Claims submitted after 90 days will be denied.

If a member leaves the employer health insurance plan, their runout period would start on the last day they were covered by the plan.

Claims that aren’t submitted by the runout deadline will be denied.

Members are informed of their runout deadline in the benefit reset date section of their benefit page.

If a member’s insurance carrier takes too long to send their EOB and they do not believe it will be received before the runout deadline, the member is required to contact Garner before the runout period deadline. 

Any claim or contact made after the deadline will not be processed.

When contacting Garner, the member should clearly outline the following details:

  • Patient name

  • Date of service

  • Services rendered
  • Garner recommended provider

The runout period can be extended by 90 days to account for a delayed EOB if the member contacts us in time. The deadline cannot be extended further, even if the member doesn’t receive their bill in time.

All of our programs function through employer-sponsored health plans. Garner Health is not an insurance company.

Garner Health is a Medicare Qualified Entity.

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