Whether you’re planning a routine checkup or major surgery, you or your health care provider will need to file a claim. Not sure how the claims process works? Here’s a quick primer.
What Is an Insurance Claim?
An insurance claim is what triggers the reimbursement for your health care costs.
Typically, your provider will submit a claim directly to your insurance company. If you’ve paid out of pocket for health care services covered under your plan, you can also submit a claim for reimbursement yourself.
When and How Do I File a Claim?
Out-of-network doctors may not submit a claim directly to your insurance company. In these situations, you’ll have to submit a claim on your own.
To file a claim:
- Get ahold of the claims form. Call your insurer or go to their website to find out what information you’ll need before you file the claim. Be prepared to at least give your policy number, any diagnostic codes and the amount billed for each code. Requesting an itemized bill from your provider should supply you with all of this info.
- Fill out the form and submit it. You might even be able to do this electronically. Submit a separate form for each claim, and keep in mind that some insurance companies have a time limit for when you’re allowed to submit. Check your policy to find out these deadlines.
- Wait for an Explanation of Benefits. Once your insurer has processed the claim, you’ll receive a document that details what they’ll pay for. Reference this and your final bill to find out what wasn’t covered — and what you’ll have to pay for out of pocket.
If you’re unsure of the final amount or have questions, call your provider’s office for more information. They should be willing to walk you through this process step by step so you can leave the stacks of forms behind and get back to your life.