What Access to Specific Claim Data Do Employers Have?

Only authorized employer users have access to claims information. This ensures that sensitive health data is protected and handled in full compliance with HIPAA privacy rules.

What’s Included in Claims Information

Claims data typically contains details submitted by providers and pharmacies when members receive care. This can include:

• Dates of service
• Type of service or procedure performed (e.g., office visit, lab, surgery, prescription)
• Billed amounts and allowed amounts
• Provider information (e.g., hospital, clinic, specialist)
• Plan payments and member responsibility
• De-identified claim identifiers used for reporting and analysis

This information is essential for understanding how the plan is being used, identifying cost drivers, and managing overall plan performance.

Employer Access to Claims Data

Employers can access aggregate and de-identified claims data through reporting tools and dashboards. This includes:

• Total medical and pharmacy spend
• Utilization trends by service category
• Cost comparisons over time
• Shared savings and performance summaries

Employers do not have access to:

• Member-specific claim details tied to names or identifying information
• The member portal or any PHI without proper authorization
• Individual claim line items unless specifically permitted under HIPAA rules

This structure gives employers the visibility they need to manage plan costs and performance while maintaining strict privacy protections for employees and dependents.