Get answers to all your questions about Garner

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.

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.

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.

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.

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

Yes. Because HRAs are group health plans, they are also subject to certain provisions of the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code of 1986 (Code), including the need to provide a legal plan document in writing. A Summary of Benefits is not considered an HRA Plan Document or HRA Summary Plan Description (SPD). For a copy of your SPD or SBC, contact your Garner account manager.

Yes. Garner is committed to protecting the privacy of our members and to ensuring that any member data we process is secure. To this end, Garner is fully HIPAA compliant and is constantly working with information security professionals to test, review and enhance our controls and other protective measures, and to ensure compliance with applicable regulations and industry standards. Garner’s efforts were recently validated as part of our SOC 2 Type II audit review, as part of which an independent, professional third-party auditor reviewed our security, availability, processing integrity, confidentiality and privacy standards and issued a “clean” opinion with zero noted exceptions.

Moreover, Garner will never ask you to provide, or expect you to provide, any information if doing so would constitute a violation of HIPAA. Garner acts as a third-party administrator (TPA) to employers that sponsor health insurance plans for their employees. In this relationship, the employer is a covered entity, and Garner, as TPA, is a business associate of the employer. Under HIPAA, a covered entity may share personal health information with a business associate where the business associate is HIPAA compliant and needs the information to perform the services for the covered entity. Because Garner is HIPAA compliant and needs certain medical information to perform the TPA services for the employer (importantly, to process reimbursement payments for claims made under the HRA), sharing this information with Garner is permitted under HIPAA.

No. Members cannot use their HSA and HRA for the same expense.

For clients that have a claims feed, Garner tracks employees’ out-of-pocket spend to ensure they meet the required minimum before being reimbursed for qualifying costs.

For clients that do not have a claims feed, Garner asks members to attest that they have met the minimum before submitting claims.

PCORI fees were implemented as part of the Affordable Care Act. They are used to fund the Patient-Centered Outcomes Research Institute (PCORI).

The PCORI Fee is due no later than July 31 of each year for all HRA plans that ended during the preceding calendar year. For example, if your HRA plan year ended on June 30, 2021 or December 31, 2021, your PCORI fee filing is due no later than July 31, 2022. If your HRA plan year ends on March 31, 2022, then your PCORI Fee filing is due no later than July 31, 2023.

The fee for HRAs is calculated per covered employee (i.e., covered dependents do not need to be counted). See 26 CFR § 46.4376-1(b)(vi). Different rules apply to self-insured major medical group health plans. Your Garner account manager will provide you or your broker with a summary of fees prior to the PCORI deadlines.

The eligibility portal helps you manage your employee eligibility from a single location. The portal allows you to:

• View and search all eligible employees who have access to Garner

• Add new employees and edit existing employee records, including:

  • Update contact information

  • Make changes during qualifying life events

  • Terminate coverage when employees leave your organization

Learn more about how to use the eligibility portal.

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.

• 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.

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.

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.