HEALTH CARE - HEALTH INSURANCE CLAIMS - PROCEDURES

 HEALTH CARE - HEALTH INSURANCE CLAIM-WHEN AND HOW TO FILE 

A health insurance claim arises when we request reimbursement or direct payment for medical services obtained by us. The way to obtain benefits or payment is by submitting a health insurance claim through a form or request. There are two types that we can file for a health insurance claim. The first and the most convenient type is that our medical services provider can submit the claim directly to the insurance company through the network on internet. The second type is filling in the health insurance claim form and sending it by ourselves. If our health service provider is not in the network for our health insurance company and can not file the claim on our behalf, then we shall have to file a health insurance claim form to request payment for the medical services obtained. Health insurance claim is what we or our health care provider communicates to our health insurance company that we have received a health care service for which we are entitled to, from our insurance policy. 

HEALTH INSURANCE CLAIM:

A health insurance claim is more or less a detailed invoice wherein the details of health care services received by us along with the request for payment amount. Details in the claim include information about treatment, such as the dates of treatment, description of service and the charges for medical service along with the information about the service provider. Further the claim shall have the information of the policyholder's name and identification details,viz., member's number, date of birth or even a social security number, information about the insured or person who received the service, in case the patient is other than policyholder, such as spouse or dependents. 

FILING HEALTH INSURANCE CLAIM-SOME TIPS: 

Though we may file the claim on ourselves, our doctor or health care provider often files the claim for us. This is most common practice when we use in-network providers. If it is an out-of-network provider, the service provider can file the claim for us or not. If our out-of-network provider doesn’t file the claim, then we shall have to file on ourselves. Almost all health plans have a paper or online form for filing a claim. For filling out the claim form and for filing the claim by ourselves, information like the doctor or health care provider’s name and address, the dates we received the care/treatment and the insurance codes used to define our diagnosis and kind of service doctors provided would have to be obtained . 

EXPLANATION OF BENEFITS: 

Sometimes health insurance companies may ask for some more information after the claim is initially submitted to complete the processing of the claim. Then we have also to submit the needed information. However as per our health plan, when processing the claim is completed, the insurance company sends an explanation of benefits (EOB). The Explanation of benefits shows for which services the claim was made, how much the insurance company admitted and the difference of the amount payable by us in respect of this claim in settlement of the claim. 


When the claim is processed by the doctor or Service provider (Hospitals), the take every care in submitting all the information required by the insurance company at once and the claim will be got settled expeditiously, in almost all cases within 24 hours. If the claim has to be made by ourselves, then we have to take a little care in submitting full details and all connected papers as attachments in one go, then the claim gets settled fast without any procedural delays.