He was vomiting blood in the morning and we quickly rushed him to. Veterinary emergency, uh, group in Alexandria. He had a severe discomfort and pain. And uh he panicked and took him.
Pre-Existing Conditions
Claim Lifecycle
Next
Claim Overview
Policy Information:
Policy Started On: 9/5/2022
Illness Eligible From: 8/19/2022
Cruciate Coverage Eligible From: 2/5/2023
Policy Type: OG policy, Vet Visit Fee add-on, basic Prev Care add-on
The submitted invoice is below (client information intentionally omitted, vet clinic info cropped for space):
How would you proceed with this claim with the information provided to you? Do we need additional medical records? Why or why not? Think about before proceeding to the following page!
Next
Claim Investigation Determination
Done thinking? Click on the image below to see how you should proceed with this claim!
Do we need additional medical records?
Do we need to review additional MR?
Defend your reasoning!
Next
Claim Determination
Bonus question! How would you handle the rest of this claim?
What would we tag this condition as, if needed?
Pre-existing
Illness waiting period
Ortho Waiting Period
Cruciate Waiting Period
Behavioral
Dental
Bilateral
UW
Reveal Answer!
End
The tag should be: It's eligible for coverage, so no tag necessary. Why?: Gastrointestinal issues were marked as re-eligible by a previous Claim Advocate and there's no indication that we should not cover this claim. As such, it's eligible for coverage with no further Claim Investigation.
Do we need MR?: No Do we need to review additional MR?: No Why?: A previous claim Advocate has marked abnormal gastrointestinal lab values as re-eligible. Once they've done their due diligence to determine if a curable condition is re-eligible, there is no additional need for future Claim Advocates to continue digging for information unless there is reason to do so (e.g., updated information in DOL MR or claim media indicates it never fully resolved).
Claim Advo CE - Scenario #3 - Tashi
Lemonade
Created on October 16, 2025
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Transcript
Scenario #3
Tashi
Start
TL;DR + Claim Media
He was vomiting blood in the morning and we quickly rushed him to. Veterinary emergency, uh, group in Alexandria. He had a severe discomfort and pain. And uh he panicked and took him.
Pre-Existing Conditions
Claim Lifecycle
Next
Claim Overview
Next
Invoice
The submitted invoice is below (client information intentionally omitted, vet clinic info cropped for space):
How would you proceed with this claim with the information provided to you? Do we need additional medical records? Why or why not? Think about before proceeding to the following page!
Next
Claim Investigation Determination
Done thinking? Click on the image below to see how you should proceed with this claim!
Do we need additional medical records?
Do we need to review additional MR?
Defend your reasoning!
Next
Claim Determination
Bonus question! How would you handle the rest of this claim?
What would we tag this condition as, if needed?- Pre-existing
- Illness waiting period
- Ortho Waiting Period
- Cruciate Waiting Period
- Behavioral
- Dental
- Bilateral
- UW
Reveal Answer!
End
The tag should be: It's eligible for coverage, so no tag necessary. Why?: Gastrointestinal issues were marked as re-eligible by a previous Claim Advocate and there's no indication that we should not cover this claim. As such, it's eligible for coverage with no further Claim Investigation.
Do we need MR?: No Do we need to review additional MR?: No Why?: A previous claim Advocate has marked abnormal gastrointestinal lab values as re-eligible. Once they've done their due diligence to determine if a curable condition is re-eligible, there is no additional need for future Claim Advocates to continue digging for information unless there is reason to do so (e.g., updated information in DOL MR or claim media indicates it never fully resolved).