Health Insurance Claims

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Written by Trusted Choice

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Reviewer: Jeffrey Green Reviewed by Jeffrey Green
Reviewer: Jeffrey Green
Reviewed by Jeffrey Green

Jeff Green has held a variety of sales and management roles at life insurance companies, Wall street firms, and distribution organizations over his 40-year career.  He was previously Finra 7,24,66 registered and held life insurance licenses in multiple states. He is a graduate of Stony Brook University.


Health insurance claims are health insurance in action. The very reason we buy a healthcare policy 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 treatment, 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 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.

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.

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 Plans

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 reimbursement for treatment sought for prolonged illnesses, cognitive disorders, degenerative conditions, or other chronic health issues.

Health Savings Accounts

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. 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 reimbursement for any covered family member’s medical expenses.

 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. If the bill for your care services is $100, you pay your share of $25 and the healthcare provider collects the additional $75 from your insurance company. 

 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 the 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 for internal appeals and external reviews.

You have the right to know why your claim was denied. Your insurer has to tell you the reason for your health insurance claim denial or reconsider the claim. This is called an internal appeal. 

If the internal appeal doesn't change your insurer’s decision, you have the right to ask another party to review the decision of your insurance company. This is called an external review.

Working with an Agent for Your Healthcare Needs

Local independent agents 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 insurance agent today and get the right healthcare coverage for your needs and budget.

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