This is the entire procedure how the process of filing a health insurance claim operates
- Understand your health plan.
- Are there network providers included in your health plan?
- Can you see providers outside of your network with your health plan?
- What are the amounts for the deductible, copay, and coinsurance? You have to pay them when?
- Does receiving treatment require a referral or pre-authorization?
Consult your healthcare physician.
- Verify that your healthcare provider and your health plan are both covered by the same network.
- Inquire with your healthcare provider about how they bill for treatments and how they collect your deductible, copay, and coinsurance.
- Your health plan is billed directly by network providers. You might need to request reimbursement from your insurance because out-of-network physicians are exempt from billing your health plan.
Examine the Explanation of Benefits (EOB) and your bill.
- Network providers: Verify your bill against the EOB and make the required payments as specified by your health plan.
- Non-network suppliers: For information on claim forms and deadlines, contact your health plan. It could be necessary for you to reimburse the provider and request reimbursement from your health plan. Before you pay your provider, try to find out how this works with your health plan.
- In certain cases, an out-of-network provider is required to bill your plan and is unable to charge you for services that your plan will cover. Study up on balance billing.
Issues or disputes with claims
- To find out what is covered and how to appeal decisions, read your health plan contract.
- Speak with your provider and health plan. Prior to appealing, try to fix the issue.
- Submit an appeal to your health plan if you are unable to fix the issue.
- Remember when you have to turn in your appeal paperwork.