What do claims assistance professionals (CAPS) do?

• A. Administer pharmaceutical therapies.
• B. Provide clinical case management.
• C. Help patients organize, file, and negotiate health insurance claims to maximize benefits.
• D. Develop payer contracts.

Answer: (C)

CAPS help patients navigate health insurance claims to maximize benefits by organizing all necessary documentation, filing claims accurately, and pursuing appeals or negotiations when needed. They collect and assemble items like insurance information, medical records, itemized bills, and explanation of benefits, then submit claims and track their status. They explain coverage details such as deductibles, copayments, coinsurance, and prior authorization requirements, so patients understand what the insurer will pay versus what they owe. They also coordinate with providers to ensure correct coding and documentation support, and assist with denials or errors through appeals or negotiations to recover or maximize payment. This role focuses on the claims process and payer interactions, not on delivering therapies, coordinating clinical care, or creating payer contracts.