The Health Insurance Claims Process

Having health insurance is one thing, but what happens when you need to file a health insurance claim? Unfortunately, there's no one straightforward answer to this question. The reason is because every type of health insurance plan generally includes its own way of handling claims. And when you stop and consider the number of companies offering multiple types of health insurance policies, you can begin to understand why answering such a seemingly simple question can be so complex.

If you need help understanding how to file a health insurance claim for a benefit that is covered under your health insurance policy, the best place to begin is with the insurance company itself. Most will offer a toll-free telephone number that is staffed during normal business hours that you can call. You'll typically be first required to provide some basic information about your policy including the policy or group number and the name of the primary insured on the policy. From there, the insurance company representative can access the details of your health insurance policy and advise you how to proceed with your claim.

If you have a Managed Care Plan and you're dealing with a covered benefit, you'll find that the process is surprisingly simple. Most often, those staffing the front offices of the medical facilities you visit take care of processing the necessary paperwork. They input the proper medical codes for the services rendered and send the paperwork to the insurance company. Patients typically make the required co-payment at the time services are rendered and need take no further action until they receive from the insurance company the paperwork that corresponds to the office visit. The paperwork shows the percentage that the insurance company paid, how much was applied towards the deductible, and it will show if there is a balance due by the patient.

In the past, those with Indemnity Plans were required to pay in full for the services rendered at the time they were rendered. They were given lengthy claims forms to complete and submit to the health insurance company. It would take weeks to get reimbursed for the services provided. But today, front office personnel typically will directly bill the insurance company for the services rendered first and then they'll wait to see what percentage the insurance company pays. In situations where there is a balance due afterwards, the patient is billed. Anytime there's a dispute, the medical services provider bills the patient directly and the patient does need to pay. It's then the patient's responsibility to work out an agreement with his or her health insurance company.

With all the computerization involved in the medical billing process today, patients typically don't have any out of pocket costs aside from their co-payment. If they are required to first meet their deductible, the paperwork still gets forwarded to the insurance company first, so that those in charge can keep accurate track of the policy's usage and payment history. Given the enormity of the task, health insurance claims for covered benefits get settled rather quickly.