Eliott Dear on the Claims Assassins Intake Sort: Fully Insured vs. Self-Funded

Every claim that comes into Claims Assassins gets sorted at intake. That sort is the most important decision in the entire workflow, and it happens before anything else. Eliott Dear sorts each claim on one dimension: fully-insured or self-funded. The answer determines the venue, the benchmark, and the regulator. Getting the sort wrong puts the claim in a forum that cannot hear it.

Two Types of Plans

Every commercial health plan in the United States falls into one of two structural categories. Fully-insured plans are contracts between the employer and a commercial insurance carrier, where the carrier assumes the underwriting risk. Self-funded plans are where the employer assumes the underwriting risk directly and contracts with an insurance company only for administrative services.

That distinction, which sounds like a financial arrangement between an employer and a carrier, determines which legal regime applies to the plan. Fully-insured plans are regulated by the state Department of Insurance. Self-funded plans are not governed by state surprise billing law.

Why It Changes Everything

The regulatory regime determines which surprise billing law applies. New York’s surprise billing framework, with the FAIR Health 80th percentile benchmark, applies to fully insured New York plans, and DFS administers New York State IDR. A self-funded plan sits outside that framework.

Eliott Dear files New York State IDR for fully insured New York plans, and the self-funded claims are kept out of the state forum. Sorting the claim correctly at intake is what decides whether a physician’s claim belongs in New York State IDR at all.

How Eliott Dear Classifies

Plan classification is not always visible on the EOB. Insurers do not print “fully-insured” or “self-funded” on the explanation of benefits. Eliott Dear uses a combination of signals: the patient’s employer name, the plan name, the member ID prefix pattern, the group number, the plan type code in the payer master data, and patient alerts inside the billing system that identify the funding structure.

The same carrier can administer both fully-insured and self-funded plans. The same carrier name on the EOB does not tell you what regime applies. Two claims from the same insurance company for the same CPT code can end up in entirely different venues based on which plan the patient is enrolled in.

The Point of Sorting

A non-par billing service that does not sort at intake is going to file some of its self-funded claims into state IDR, where the arbitrator will dismiss them for lack of jurisdiction. It is going to send some of its fully insured New York claims somewhere other than New York State IDR, the forum built for them. Both errors start with skipping the sort.

Eliott Dear does the sort because doing it right is the entire reason the practice exists. At Claims Assassins the routing is settled upstream, before anything is filed: fully insured New York claims go to New York State IDR, where the submission is prepared, attorney-signed and filed into the process DFS administers, and self-funded claims never land in a state forum that cannot hear them. Nothing about a filing is magical once it is submitted; the work that matters happens at intake.