By definition, a health insurance claim is what a doctor submits to your insurance company after providing you with a procedure or service so they can get paid. The claim will list the medical services that were provided for you.
If it’s your first time looking into health insurance for yourself or someone else, then you are likely to have many questions. Health insurance can be confusing, especially if you’ve never dealt with it before, so having various questions is normal. Health insurance claims are detailed invoices that specifically explain what a person is being billed for.
How does the insurance claims process generally work?
Typically, your doctor’s office will submit a claim and you will not need to be involved in the process. Your doctor will send a bill to your insurance company for any charges you did not pay during a visit or submit a claim for the services they provided to you during your visit.
Then, a claims processor will check it. They check the claim for completeness, accuracy, and whether the service is covered under your health insurance plan. They will also verify other important information like your copay and how much of your annual deductible and out-of-pocket maximum you have already paid throughout the year.
If the service is covered, the insurance company will pay the doctor. Depending on the benefits included in your health insurance plan, they will pay the entire cost of the service or a portion.
Once the claim is processed, you will receive an Explanation of Benefits (EOB) that details how the care you received was paid by your plan. You may also receive a bill from your doctor during this time for any charges left unpaid by you or your insurance company.
After you receive the final bill from your doctor, compare your final bill with your EOB. The information on the EOB should match the amount you owe your doctor as listed on the bill.
Who files health insurance claims?
Typically, you will not have to submit a claim yourself. Most healthcare providers take care of this process.
However, if you ever need to file an insurance claim yourself here are some tips to make sure your claim gets processed smoothly:
- Write clearly and legibly
- File your paperwork promptly and within the time
limit - If needed, include preapproval
- Include all necessary information
- Include procedure codes (you can get these from
your doctor’s office) - Make sure to use the claim form from your
benefits plan - Verify that the services you received are
covered by your specific plan
Apart from having to submit the paperwork yourself, the claim processes the same way. However, you may have to pay your doctor upfront and wait for a reimbursem*nt from your health insurance company.
Health Insurance Claims: FAQ’s
What should you do if a health insurance claim is denied?
If a health insurance claim is denied, then you shouldn’t panic. Every health insurance plan offers an appeals process that allows you to request that the health insurance plan review the bill a second time. The insurance claims process can be complex, and there could have been a mistake of some sort that caused your claim to be denied. While there is no guarantee that your health insurance claim will be covered simply because you filed an appeal, if you’re quite sure that the claim should have been paid, then there is a good chance that filing the appeal will be successful.
Can eHealth help you with your health insurance claims?
Yes, eHealth agents can help beyond just finding a health insurance plan. They can assist you with your health insurance plan in a variety of ways. First of all, eHealth can assist you with understanding your claim, because even though the claim should be detailed and explain why you’re being charged for what, it can be difficult to understand. eHealth can explain the invoice to you in a manner that you can understand, so you will know exactly why you’re being charged what.
eHealth can also assist you when it comes to how to handle a health insurance claim that is incorrect. In most cases, you will be advised to file an appeal, but if you’re not sure how to go about filing an appeal, eHealth staff can walk you step-by-step throughout the process to ensure you’re filing the appeal correctly.
How much does it cost to file a health insurance claim?
The cost of filing a health insurance claim depends on the type of claim, as there are cashless claims as well as reimbursem*nts. When it comes to a cashless vs. reimbursem*nt medical insurance claim, cashless claims don’t have to be paid by the recipient of the health care plan.
In other words, whenever you need treatment, you can obtain medical care at a hospital, urgent care center, etc. and not have to worry about paying out-of-pocket at the time services are rendered. This doesn’t mean that you won’t have to pay your share of the costs, but you will receive a bill from the facility you received treatment from once your insurance plan has paid what it has been contracted to pay.
Reimbursem*nts mean that a member must pay for care upfront, and if the medical treatment is covered by the health insurance plan, then the member can file a request to receive reimbursem*nt through their insurance plan. Once your medical insurance plan has time to review the request, if everything appears in order and the service was covered, then you should receive a check in the mail.
How to find health insurance coverage
Did you know that when you sign up for a plan with eHealth, our help doesn’t stop after you enroll? We’re here to help long after you’ve purchased a plan! If you have any questions or need help with your plan, you can count on eHealth to be your insurance ally. Start using our health plan comparison tool and find your individual and family health insurance plan with eHealth today. Let’s find the right plan, together.
