Steps in Processing Health Insurance Claims

Inquire at the doctor's office about health insurance claims.
i Jupiterimages/Creatas/Getty Images

The first step in the health insurance claims process involves you, the insured. Get information from your health care and insurance providers to avoid unexpected costs or paying for something only to find out you’re not covered. Do this in advance of treatment or after you become insured to help the process flow smoothly when the time comes. The more you know, the faster the process starts.

Keep Records

Contact the medical office and insurance company about paperwork, confirming if you are responsible for filing papers for the insurance company or if it will be handled between the health care and insurance providers. Keep statements and details you get at the office or through the mail for your own records in case of disputes. Get to know the people you have spoken with and check back with them to make sure the proper paperwork has been received to avoid any delays or confusion.

Filing the Claim

Submitting a claim to the insurance company depends on your plan. The doctor or care provider usually sends the bill for payment to the insurance company, which reviews the statement for processing. You will need to file the claim yourself if you have a managed plan and receive care outside the network or if you have indemnity insurance, which has fee-for-service coverage. People with individual policies might mail in information, call the insurance company or file online, depending on the insurer’s claim process. A representative will check your eligibility when you provide your identification and policy information.

Determining Payment

Initial claim processing by the insurer includes confirming eligibility for the treatment and making sure you filed your claim within the time limits. Insurers look at the date and place of the service and whether the appropriate treatments for the condition were given. The insurer also verifies the services were accurately reported by the health care provider or individual. The insurance company then decides to pay the claim in full, pay it at a reduced level if your policy covers less, or deny the claim.

Claim Denials

You could end up with a denial for a claim if you filled out the insurance forms the wrong way or didn’t file the claim within the time limit specified in your policy. Denials also happen for treatment excluded from your policy, or if you didn’t receive approval from the company for treatment. Speak with the representative of the company immediately if you have been denied a claim. Keep all records of your discussions. If your claim is still denied and you feel you’re entitled to coverage or reimbursement, contact your state’s insurance regulator, who reviews your case. Success of an appeal depends on your state. Some states take stronger action than others to protect consumers. The last resort would be hiring a lawyer to take the insurance company to court or reach some sort of settlement.

the nest