Lifestyle | Managing Money

Step by Step in Health Insurance Claims

June 21, 2023

The healthcare claims process is vast, complicated, and fascinating. It’s also confusing.

After a doctor visits a patient, the office will fill out an insurance form, typically sent to a third party for processing. The first step is to make copies of all forms and itemized bills.

Obtain Itemized Receipts and Bills

A medical bill is an important document containing the individual charges for services a patient or hospital receives. It allows patients and insurers to understand the specific cost of a procedure, enables claims processing, supports dispute resolution, facilitates tax deductions and reimbursements, and helps patients with budgeting and healthcare decision-making. Itemized bills, also known as superbills, fully account for the costs of a patient’s care and are often used when disputing billing errors.

Typically, doctors or hospitals will send the itemized bill to their patients after the insurance company has acted on it and determined how much remains to be paid. The insurer may also provide an Explanation of Benefits (EOB) form containing this information.

The best thing to do when disputing a bill is to wait to pay it, especially if you haven’t had a chance to review it carefully. This will give you a better chance of successfully appealing the claim and prevent your credit score from being damaged by unpaid charges.

Start by requesting an itemized bill from the clinic or hospital where you received treatment. Compare the codes and descriptions of services in the itemized statement with those on your EOB to ensure they match, and look for duplicate charges. This is the best way to find and address any errors. If the items on the itemized bill need more accuracy, contact the hospital or clinic and ask to speak with a representative. Be polite and explain that you are requesting a change in the charges to reflect what you received and your financial situation.

Fill Out the Claim Form

Health insurance claims can be confusing and full of jargon. It is important to dot your I’s and cross your T’s to ensure your claim will be processed quickly and accurately.

The CMS-1500 claim form is the standard form that healthcare professionals use to submit medical claims to Medicare and other insurance providers. The form was designed to simplify and streamline filing medical claims by standardizing submissions nationally. Most insurance carriers accept digital copies of the CMS-1500 claim form, which makes the process much faster and more accessible for everyone involved.

When filling out the form, include all of your itemized receipts and bills and any other documents supporting your claim. These may include a hospital discharge report, summary report, or case file. In addition, be sure to complete all required fields on the form, especially those related to your medical history and procedure codes. Also, remember that any reimbursement you receive from your health insurance company is only valid in line with the sum insured limit you have chosen.

If you have any questions about submitting your claim, contact your doctor or the office staff and ask for assistance. 

Submit the Claim Form

When you have your itemized receipts and bills and have filled out the health insurance claim form, it’s time to submit it. Typically, your doctor or healthcare facility will take care of this for you, especially if they are in a network with your insurance provider. However, you’ll have to do this yourself if they aren’t or you have out-of-network coverage or a deductible.

The form will tell your insurer about your visit, what was done, and what was billed to you. It will also give the insurance company instructions on other documents they may need from you, your doctor or health care facility, and your medical records to process the claim correctly. Call your health insurance company to get more information and to find out how long you should expect to wait to receive your payment once the claim has been processed. Mark that date on your calendar and contact the health insurance company if you are still waiting to receive your payments within that timeframe.

If your claim is denied, file an appeals request with the insurance company as quickly as possible. The denial may be due to a simple mistake or the information you provided was missing or incorrect. To proceed with the procedure or treatment, you will be required to provide supplementary documentation, such as a letter from your doctor explaining the necessity of the procedure or treatment. Once the appeal has been processed, your insurance company should pay your doctor and send you an Explanation of Benefits (EOB).

Receive Payment

Ideally, your healthcare provider will file a claim on your behalf and submit it to your insurance company for payment. But if they are out of network, you may have to file the claim or pay for services upfront and seek reimbursement from your insurance company. Once the insurance company processes your claim, they will send you an explanation of benefits. The EOB lays out a detailed list of the services provided, how much was covered, and what remains to be billed to you, including copayments, coinsurance, and deductible amounts.

The whole claims process can be complicated and involves many steps. Medical billing requires a high level of accuracy, so ensuring that demographic information like name, address, date of birth, insurance policy number, and contact information are complete before the patient leaves the office is crucial. Many doctors will use a clearinghouse that translates clinical information into a standard format for submission to payers. These organizations provide an extra layer of protection against errors since they can review the claim before it is sent to a payer.

Dealing with the claims process can be frustrating, mainly when a claim is mistakenly denied. If you receive a denial notice, your health insurance company will provide instructions on filing an external appeal. The appeals process can take up to four months. 

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