Manually substantiating a transaction in My Care Card

When a member completes a transaction using a card in his or her profile, the transaction is evaluated to determine whether it is an eligible expense. If the transaction is determined to be eligible, it is automatically substantiated and no further information is required for the transaction. Transactions that are not substantiated at the point of sale must be reviewed. My Care Card helps you monitor the transactions in the substantiation review process.

Transaction is not substantiated automatically

If a transaction is not automatically substantiated, My Care Card automatically assigns the Pending status to the transaction and records the current date as the Substantiation Status Date. Once the Pending status is assigned, a notification is sent to the member requesting that he or she provide a receipt or other documentation proving that the transaction is valid. If the member does not respond, up to three more notifications are sent after which the member's cards may be blocked.

TPA reviews provided documentation

When the user provides the requested documentation, the TPA reviews the transaction. The TPA uses My Care Card to change the Substantiation Status to Approved, Ineligible, or Pending More Info. If the transactions is assigned the Approved status, then no further action is required. The transaction is substantiated and the Substantiation Status Date is updated.

More information is needed

If the transaction is reviewed but more information is needed, the TPA uses My Care Card to change the Substantiation Status to Pending More Info. My Care Card updates the Substantiation Status Date. The member is sent a notification that additional supporting documentation is required. Members will receive three notifications that they need to provide more information before their card is blocked. When the information is received, the TPA uses My Care Card to change the Substantiation Status to Approved or Ineligible. If the transactions is assigned the Approved status, then no further action is required. The transaction is substantiated and the Substantiation Status Date is updated.

Ineligible transaction

When a transaction is reviewed and determined to be ineligible, the TPA uses My Care Card to change the substantiation status to Ineligible, the Substantiation Status Date is updated, and a notification that the member must reimburse the plan is sent. Members may receive up to three notifications that they need to reimburse the plan before their cards are blocked.