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Health Insurance: Filing a Claim

(6/6/2012) A claim for health insurance is a request for payment from your insurance company. With many insurance plans, you don't need to worry about submitting claims. You are required to pay a co-payment for services rendered, and for the remaining costs beyond that co-payment your health care provider submits claims for reimbursement.

But with some plans, and for some services in different plans, you may be responsible for submit health insurance claims yourself.

To ensure an easy filing process, and the maximum reimbursement received, follow these tips:

ASK AHEAD
Is your doctor covered by your insurance? Is your visit covered? And are any services that will be part of that visit, including x-rays, lab tests, etc, covered? To make sure you don't get hit with any unexpected costs, and that your claim will be ultimately accepted by your company, ask your doctor or medical facility, or your insurance company, these questions before your visit.

DOCUMENT
Keep any and all receipts from your visit. If you need to make upfront payments and get reimbursed later, make these payments and get all the receipts (with insurance codes noted) you can. Request an itemized bill from your provider that lists all services, fees, and necessary insurance codes associated. You'll need these to accompany your insurance claim.

COMPLETE FORMS
Obtain a copy of the claim form you need to complete from your insurance company. Often these can be found on the company's website or in your customer portal. The form will ask basic questions about your insurance information, the recipient of any payments, the reason for the services, and any additional queries needed from your specific insurance company. Fill out the form in its entirety, and be sure to get any questions answered by talking to a representative - don't guess.

FILE
Submit the form as instructed by your company. Make copies of the form and the supporting documents you're attaching to help eliminate any errors made in the claim process, or to refile in case something gets lost. Be sure to send the form in a timely manner - some insurance companies require a claim be filed within a certain amount of time following your visit.

FOLLOW UP
Most claim forms will pinpoint a window in which your claim will be processed. Keep this timeframe in mind, and follow up with your company if you don't hear anything within that time.

Following these steps are a major step towards a successful claim. In many cases, if a claim is denied by an insurance company it is for failure to follow one of these steps above. But there is always a possibility that claims will be denied even if these steps are followed to the letter, if your plan doesn't cover a specific procedure, medical or supply, or if the company considers the service medically unnecessary or experimental. If you claim is denied, your first step should be to call the company. A calm discussion can often resolve any situations of denial. If that doesn't work, you can request a formal review by a health care professional specializing in the field of your service.

A frequent contributor to ERATE® since 2006, Amy Lillard is a freelance writer specializing in turning complex information into useful tips and tricks for readers. For questions or topic suggestions, contact Amy at [email protected].