Understanding health insurance claims can be complex and confusing. It is important, therefore, to know how to navigate the challenging but important process of submitting insurance claims and appealing denials or underpayments.
Key Steps for Submitting a Claim
Submitting a claim to your health insurance company requires gathering specific information and documentation.
First, you need the proper medical billing codes used by your doctor or healthcare facility. These standard codes describe exactly what diagnoses and procedures were performed. The experts over at Find-A-Code.com say it’s crucial to have the correct codes, as insurers rely on them to know what services were rendered and determine coverage and payment levels.
Besides the billing codes, you also need to provide your insurance ID or member number, which is printed on your insurance card. Be sure to check if you have a copay or deductible payment required, and whether the specific medical services are considered in-network according to your policy.
Additionally, your claim must include the provider’s name, complete address, tax ID number, and National Provider Identifier (NPI) number for reimbursement processing.
Other key details are the exact date when services were rendered, a descriptive listing of all procedures and care performed, plus the total billed charges for everything. Organize this into a proper claim form, attach any supporting documents, and submit it to your insurance company by mail or electronically. Always keep copies of your records as backup.
Waiting for Claims Processing and Payment
Once you submit your insurance claim, it goes through a series of steps and reviews at the insurance company before a determination is made. The initial claims processing can take anywhere from 30 to 90 days to complete.
First, the insurance company does an initial validation check to make sure all required information is present and accurate on the claim form. Any errors or omissions can delay processing timelines.
Next, they review the specific terms of your policy coverage to see what benefits may apply to the services rendered and what your coverage includes or excludes. Then they apply standardized pricing guidelines to determine the allowed reimbursement amount they will pay for the coded procedures.
After processing is complete, you should receive an Explanation of Benefits (EOB) statement from the insurance company. This outlines exactly how they processed and paid out the claim. It will show the original billed amount, any reductions or denials, the allowed approved reimbursement amount based on your policy, and any remaining amount that is your responsibility.
Follow Up on Unpaid or Denied Claims
If your claim is left unpaid or is denied, it’s important to follow up promptly to dispute the outcome. Unpaid claims may simply need more time for processing, but you should check status after 30 days. Denied claims require action on your part to overturn the denial and get the claim paid.
Start by reviewing your EOB statement to understand the exact reason given for denying the claim. Some common reasons include the service not being covered by your policy, using an out-of-network provider, lack of prior authorization, or billing errors by the provider.
If you disagree with the denial reason, you can submit an appeal letter along with supporting documentation to make your case. Provide relevant medical records, codes, policy provisions that apply, or corrected billing details. Call your insurer’s customer service to discuss the claim denial as well. With persistence and proper evidence, many claims denials can be overturned.
Conclusion
With knowledge, preparation, and expert assistance, you can tackle the complexity of health insurance claims head on. Arming yourself with all the information on the process, codes, and your policy terms will help to maximize a successful claims resolution.
