Health Insurance Claims 101
Filing a claim with an insurer starts the process of getting health care paid for. Life will be easier, and you will maximize use of your insurance, if you know:
- Whether the provider files the claim or you have to
- If you have to file a claim, how to do it
- What happens if you have more than one health insurance plan
- How to appeal if an insurer denies your claim.
Who Files A Health Insurance Claim
Whether you or the health care provider file a claim depends on the type of coverage you have and whether you are covered by more than one health plan. Our discussion is divided into:
- Medicare: See How To File A Claim Under Medicare.
- Medicaid: There is no claim to file.
- Private Insurance.
- HMO or other managed care plan:
- Without a "Point of Service" feature which allows you to receive some coverage if you go outside the plan: see Health Insurance Claims When You Are Covered By A Managed Care Plan.
- With a "Point of Service" feature: see Health Insurance Claims When You Pay Part Of The Bill.
- All other plans, including Fee-for-service (Indemnity) type plans, PPO type plans, and "Point of Service" (POS) plans: see Health Insurance Claims When You Pay Part Of The Bill.
- HMO or other managed care plan:
If you are covered by two or more health insurance plans, see: How To File A Claim When You Have More Than One Health Insurance Coverage.
To understand the terms used with respect to health insurance claims, see: Health Insurance Terms To Know.
When you file a health claim:
- Be sure to follow the insurance company's procedures and requirements. A claim may be rejected if you do not follow the requirements.
- For instance, pay attention to the dates by which claims must be filed.
- Also note requirements about where and how claims are to be presented.
- Keep a photocopy of everything you submit to an insurer (preferably in a file with all the other papers relating to your health plan).
- Keep track of what has been paid, and what has not been paid.
- This can be done as simply as keeping two folders. One folder has a copy of each submitted claim. Claims are moved to the other folder when they are paid.
- You can also keep track of claims on your computer in a word processing document or on a spread sheet by cutting and pasting claim information from one place to another. You can also manage claims with computer software such as Quicken's Medical Expense Manager
There are many stories about health insurers saying "no" hoping that people will not know enough to push the issue. Sometimes the company says "no" because the paperwork hasn't caught up yet.
If a claim is turned down by the insurance company: appeal - and keep appealing. (For "how to" information, see the document in "To Learn More.") Persistence pays off. It is worth the effort to follow up and to keep appealing. We are talking about your health, and possibly your life.
What Happens After A Health Insurance Claim Is Filed?
The insurer will send you a form generally known as an Explanation Of Benefits which is usually referred to by the initials E O B. Medicare calls this document A Medicare Summary Notice.
An EOB describes:
- The health care provided.
- What action the insurer has taken (it paid all, part or none of the bill).
- What, if anything, you have to do (such as pay part.)
- Your rights to appeal if the claim is denied, including the time period in which to file the claim.
If you have questions about any part of the EOB, call the insurer at the phone number listed on the form.
If the insurer turned down your claim, appeal.
What If You Are Covered By More Than One Health Insurance?
When you are covered by more than one health insurance plan, it is helpful to know which of your plans pays first (the "Primary Payer") and which pays second (the "Secondary Payer.")
- If you receive bills, you will know which company to send them to (the "Primary Payer.")
- If you do not receive bills, you will know which company to follow up with if there are any problems. The company to contact is the Primary Payer.
If you start with the wrong carrier, it is not awful. However, it will delay payment or resolution of your problem.
There are industry wide rules for coordination of health insurers.
How To Keep Track Of Your Claims For Medical Bills
If you are in a health plan that requires you or your doctor to file a claim so the doctor will be paid, part of your job is to keep track of your medical bills to be sure bills are paid and you are not stuck with any unexpected bills.
It is painless to keep track if you use a system. All you need is simple system which is easy to set up. For a simple method, see: Keeping Track Of Your Claims For Medical Bills: A Simple Method
If you do not want to keep track of bills yourself:
- Ask a friend or family member to help keep track for you. People want to help.
- If no one is available, consider hiring a claims professional. See Hiring A Claims Professional.
What To Do If You Are Billed Incorrectly
If you are billed incorrectly or if the insurance company refuses to pay for all or part of a medical care, first check whether the procedure code and/or description is correct.
If the reason is not a clerical error, press your case with the insurance company. This includes billing for out-of-network doctors that you did not personally engage (such as an anesthesiologist or a doctor who attended you while you were unconscious). This practice is referred to as "Balance Billing."
What To Do If The Insurer Says "No"
If you are denied coverage, appeal. Studies show that persistence pays off.
For more information, see:
- Filing a health insurance claim
- If you are covered by more than one health insurance
- After an insurance claim is filed
- If you are billed incorrectly
- If you have a question whether a medical expense is covered by your insurance, file the claim. Let the insurer tell you if it is not covered. Ask why.
- Because insurers can make mistakes, it is advisable to do the following:
- If you have a private health insurance policy with a deductible, it is advisable to keep track of your expenses until you meet the deductible. If you and the insurance company diagree about payments, you'll have proof.
- If you have Medicare with a Donut Hole, keep track of your expenses for medicine so you can compare them.
- Because of the federal law known as ERISA, you cannot be discriminated against for filing a health insurance claim.
To Learn More
More InformationHealth Insurance: Claims: Appeals