Navigating health insurance claims can be confusing. When you receive medical care, your health insurance company receives a claim for payment from your healthcare provider. As the policyholder, you may see paperwork relating to the claim and have to pay a portion out-of-pocket. This guide breaks down the key parts of an insurance claim and tips for understanding your responsibilities when it comes to paying for care.
What is a Health Insurance Claim?
A health insurance claim is a request made by your doctor, hospital, or other healthcare provider to your health insurer requesting payment for services rendered. The claim includes details like the dates and types of healthcare services, the charges associated, diagnostic codes, treating provider information, and the amount requested for reimbursement.
Once your health insurer processes the claim, they determine the “allowed amount” for the services per your policy terms. This is the maximum dollar amount your insurer will pay. The insurer then calculates how much you owe based on your cost-sharing responsibilities, which could include a deductible, copayment, or coinsurance payment.
Key Parts of an Insurance Claim
Here are the key components commonly found on an insurance claim:
Patient Information: This includes your full name, birthdate, insurance ID number, and contact details. Double-check that your personal information is accurate.
Provider Information: The claim lists details on the facility and providers who rendered treatment, such as the hospital, doctor office, or lab that supplied care.
Date(s) of Service: The claim form shows the exact date or date range when you received medical services.
Place of Service Code: A code is used to identify where you were seen, such as a physician’s office, emergency room, urgent care clinic, ambulatory surgery center, etc.
Diagnosis Codes: These alphanumeric medical codes describe the specific condition, symptoms, or reason for your visit.
Procedure Codes: These are the services, tests, or treatments that were performed during the visit. Each has an associated charge amount.
Billed Charges: This main section of the claim outlines the itemized services provided and the fees charged by your healthcare providers.
Allowed Amounts: This is the fee agreed upon by your health insurer and network providers as total payment for that service.
Deductibles, Copays, or Coinsurance: Any portion you owe out-of-pocket per your health insurance will also appear on the claim summary.
Understanding Your Responsibilities
To avoid getting stuck with a higher-than-expected bill for a health insurance claim, it’s key to understand your cost-sharing obligations under your specific plan:
Deductible: The annual amount you pay out-of-pocket before insurance covers care (except preventive visits). You foot 100% of bills until reaching this amount.
Copayment: The fixed dollar amount you pay at the time of medical services, like $30 for an office visit or prescription.
Coinsurance: The percentage you pay for the cost of care after reaching your deductible, like 20% of an emergency room visit.
Out-of-Pocket Maximum: The most you have to pay annually for covered healthcare expenses, including deductibles, copays, and coinsurance. Your insurer covers 100% of costs after hitting this cap.
Getting Organized
Save all paperwork and Explanation of Benefits statements from your health insurance company. These outline what was paid on your behalf and what you still owe.
Also, track healthcare expenses in your own records. Log details like:
- Date of visit
- Provider name
- Charge amount
- Amount you already paid
- Deductible and out-of-pocket totals
This makes reconciling bills easier when the claim finally processes and you need to pay outstanding balances.
Appealing a Claim
If your claim gets denied entirely or you disagree with the allowed amounts, you can file an appeal. This involves contacting your insurer to formally request they reprocess the charges or cover additional services.
Provide as much written detail as possible on why you disagree with their decision, along with supporting documents from your providers. Stating a clear reason, being polite, and explaining the medical necessity can help with getting a denied health insurance claim overturned.
Using In-Network Providers
Seeing doctors and hospitals within your health insurance company’s network is key. Network providers agree to accept set rates for care, limiting what you pay out-of-pocket. Services by out-of-network providers risk higher bills because charges exceed your plan’s allowed amounts.
Review your detailed provider directory offered by your insurer to find in-network options before getting care. Doing so saves money and headaches.
Conclusion
While health insurance terminology and claim paperwork can seem complicated, being an informed policyholder makes the processes more manageable. Know your coverage details, track healthcare expenses accurately, and use network providers whenever possible. Reach out to your health insurance company with any claims questions as they arise. Staying organized and aware of your plan responsibilities allows you to better understand costs when using your benefits.
