This section outlines the different claim submission pathways available to members and what they can expect when submitting a claim. With the recent enhancements to Real-Time Adjudication (RTA) and provider-submitted claim capabilities, members now experience faster, more transparent processing than ever before.
Whether claims are submitted by the member or directly by a provider, the experience in the member app and portal will vary depending on the type of benefit and submission method.
This guide will walk through each scenario to help you support members confidently and accurately.
Applies to 20+ benefit types, including:
Allied Health Providers: Acupuncturist, Athletic Therapist, Audiologist, Chiropractor, Clinical Psychologist, Counsellor, Dietitian, Foot Care Nurse, Massage Therapist, Naturopath, Occupational Therapist, Osteopath, Physiotherapist, Podiatrist, Reflexologist, Social Worker, Speech Therapist
Other Benefits: Prescription Drugs, Vision, Orthodontic Treatment (if Prior Authorization is on file)
Member Experience:
When submitting eligible claims via the mobile app or member portal, processing happens instantly.
The claim status ("Submitted" or "Processed") is visible immediately in the app/portal for full transparency.
Exceptions:
Claims requiring government coordination, COB, or initial Special Authorization/EDS forms will not process in real time on first submission. Once on file, future claims will process instantly.
Manually entering a new provider? First claim won't adjudicate instantly. Once the provider is recognized, future claims will process in real time.
Applies to services like:
Pharmacy
Dental
Physiotherapy
Massage Therapy
Plus, many others submitted directly through provider portals or point-of-sale systems
Member Experience:
Claims submitted by the provider show up as “Submitted” or “Paid” instantly in the member app/portal.
This supports a fast, seamless, and transparent experience without member action.
Applies to all other benefit types not yet eligible for Real-Time Adjudication.
Member Experience:
On submission via the app or portal, the member sees a confirmation message that the claim was successfully submitted.
Members also receive an email confirmation.
Claims will not appear in the app/portal right away. Once they enter active processing, they will then become visible.