Health insurance claims are health insurance in action. The very reason we buy healthcare in the first place is because we want coverage for our doctor visits, especially in the event of a critical health need.
When you use certain healthcare services, such as urgent care, emergency services and specialty healthcare treatments, you may need to file claims.
Filing a health insurance claim is usually not difficult. However, the claims process does not always happen quickly, and in some cases can result in a health insurance claim denial.
If you are looking for a new policy or a better customer experience, contact an independent agent in our network who specializes in healthcare coverage.
A local agent near you can make sure you have the right health plan for your needs and can help your health insurance claims go smoothly.
- Seeking treatment without authorization
- Making mistakes in claim filing
- Filing healthcare insurance claims outside time limits
- Getting treatment or medical services not covered by the healthcare policy
- Opting for medical procedures that are not necessary
When Should You File a Health Insurance Claim?
Insurance companies watch the bottom line and keep an eye out for fraudulent health insurance claims.
To avoid having your healthcare claims denied, make sure the medical service, procedure or treatment you seek is recommended and authorized by your primary care physician or a doctor you have been referred to for care by your doctor or clinic staff.
The typical times when you may need to file a health insurance claim are when you are sick or injured, when you have a procedure done that your physician has prescribed, or a family member is sick, injured, or needs surgery. You may also need to file a claim if you need urgent care services outside of regular clinic hours.
Be sure to coordinate with your health insurance company representative before any care or procedure, whenever possible, to determine which aspects of your medical treatment are covered.
Types of Health Insurance Claims
Preferred Provider Organization (PPO)
Preferred provider organizations allow the healthcare policyholder to seek treatment from a preferred healthcare provider. When you are a PPO member and use services within your PPO network, your policy typically covers those expenses.
Health Maintenance Organization (HMO)
In an HMO plan, the healthcare policy covers only the treatment sought from accredited physicians, clinics and hospitals specified in the policy.
Group Health Insurance Plan
Any individual member of a group health insurance plan can apply for claims for a range of medical expenses. With group long-term health insurance plans, the members can also claim reimbursements for treatment sought for prolonged illness, cognitive disorder, degenerative conditions or other chronic health issues.
With some health insurance policies, you can use pre-tax dollars for medical treatment, medical costs and other healthcare expenses. A health reimbursement is arranged, and you can file a claim for reimbursements for any covered family member’s medical expenses.
Another common feature in group plans today is the Health Savings Account (HSA). With an HSA, the person insured can save money for medical costs and enjoy tax advantages as well.
HSA plans are associated with high-deductible health insurance. Contact a local independent agent for additional information.
Make Sure Your Claim Is Valid
A health insurance claim is simply the bill that you or your health provider must send in to your insurer for payment of the medical services rendered to you. For example, if the bill for your care services is $100, you pay your share of $25 and the health care provider collects the $75 from your insurance company.
Or if you are in a plan that allows you to use services outside of your network, you may need to cover the costs first and then submit the bill to your insurance company yourself.
When receiving healthcare services and filing claims, read through your benefits and coverage specified in your policy, or contact your insurance company to determine if your services are covered.
Do not hesitate to ask questions or clarify the things that you do not understand. This will help you avoid guesswork about whether your insurance company will cover your health insurance claim.
As long as you understand your benefits and your claims are within the limits of your coverage, you should have no problem with the claims process.
What to Do With a Health Insurance Claim Denial
In the event your health insurer denies your health insurance claim, you have the right to appeal. As per the Affordable Care Act passed in March 2010, health plans are required to meet basic standards regarding processes of internal appeals and external reviews.
You have the right to know why your claim is denied. Your insurer has to tell you the reason for your health insurance claim denial or reconsider the claim. This is called internal appeal.
If the internal appeal does not change your insurer’s decision, you have the right to ask another party to review the decision of your insurance company. This is called external review.
Working with an Agent for Your Healthcare Needs
Local independent agents in our network who specialize in health insurance can find the right coverage for your family and help you understand your policy’s coverage. They can also assist with the claims process.
Find an independent agent from our network today and get the right healthcare coverage for your needs and budget.