If you want to file a health insurance claim, you would need a perfect understanding of the health insurance claims process. Frankly, health insurance is one of the most complicated insurance policies in the insurance industry and this complication spans even to the filing of claims.
You may have a serious reason to file a claim but your health insurance company may reject your claim. Leaving out tiny bits of details may be the reason why health insurance companies would reject claims. To avoid such occurrences, it is quintessential to understand how to file a health insurance claim.
One thing you should be expecting is a great deal of paperwork you have to fill before your claim can be paid. Well, that is just how the health insurance policy was designed and so you do not get surprises when you file a health insurance claim, I would be showing you how the process works.
Most times, you may not be involved in the claims process when it comes to health insurance. If you go to a doctor let’s say to treat a rabies infection, for example, your doctor does a quick examination, prescribes some antibiotics, and you are done.
You pay your co-pay and the doctor’s or hospital’s billing the department continues from there without bothering you. They will help you file the claim by filing a CMS-1500 form also known as a pink sheet and send it to your health insurance provider and the follow-up is usually none of your business.
This is not always the case because when you are faced with bigger medical complications and you seek healthcare from a doctor or hospital that is not within the coverage of your policy, you will have to file a claim yourself. Let me give you an instance.
Assuming you got your health insurance from Aetna and your coverage allows you to get healthcare services from hospitals within Florida. Sadly, you and your friends went hiking in the snowy mountains of Australia and you miscalculated your step and began descending from the heights of the mountains and on hitting the ground, you fractured some bones.
You were taken to a hospital in Australia because you needed urgent medical attention. Treatment is done, you will have to foot the entire bills because the hospital in Australia would have no legitimate grounds to file a claim on your behalf.
In such a scenario, you must file a claim by yourself so you are compensated for the medical bills and expenses you paid while in Australia. When such happens, you know you should be filing a claim yourself, here’s how to do so.
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How the Health Insurance Claims Process Works
Fill the Claim Form
To file a claim, you should get a claim form from your insurance provider. The claim form should be easy to get on your provider’s website so you can easily print it and fill it.
Some health insurance companies make it possible for policyholders to file their claims online. If this is the case with yours, fair enough, if it is not, you should probably get it on their website and have it printed out.
There are certain information you will require to fill into the insurance claim form. They include but are not limited to the following:
- Your policy number, group plan number, or member number depending on the kind of policy you have got
- The name of the person who received medical care whether you, your spouse, your kids, or anyone who is covered in your policy coverage
- The event that led to the treatment. Was it an infection, an injury, or preventive measures?
- Status of your insurance coverage either coinsurance or dual coverage
Sometimes there are exceptions to the events that a health insurance claim should be filed for. For instance, you work for a construction company, and one day while you were trying to clear things from the ground floor, a careless colleague caused heavy tools to fall from the top floor on you causing serious injuries to your body.
You do not necessarily need to file a health insurance claim but a workers’ compensation insurance claim. Your employer should have one in place. Human resources should be able to help you push for one.
Medical Bills and Receipts
The health insurance claims process reviews your application to determine whether the event you are filing a claim for really took place. Your insurance provider will demand proof of the event and one such proof is an itemized medical bill from your healthcare provider stating all the services they provided.
In the bill, your healthcare provider will specify all the services they offered like examinations, lab tests, X-rays, MRIs, medications given, surgery, cardiovascular tests carried out, medical equipment handed to you like braces, crutches, e.t.c.
As the doctor itemizes these services, they must add the ICD-10 code to it. The ICD-10 code is an acronym for International Statistical Classification of Diseases and Related Health Problems, 10th Revision, and is used for billing and tracking diseases and treatments.
Every diagnosis given by a medical provider has an ICD-10 code attached to it. Your doctor must be careful to add the correct ICD-10 code to whatever billing he or she makes.
Gather Your Documents
As much as you can, gather every document that relates to your health insurance policy and documents from your healthcare provider. Gather these documents and make copies of them.
The truth is, the health insurance claims process is complicated and your claims can be rejected even for something as little as a missing piece of information. I am sure you do not want that.
Be ready for anything your insurance provider will try to throw at you. Nobody wants to lose, at least not health insurance companies, hence they would do all they can to reduce the effect of your claim on them.
Before I go, I will like to show you some things that can hinder the filing of your health insurance claim.
Why Health Insurance Claim May Be Denied
Your insurance provider may reject your claims even when the pieces of evidence are clear you deserve to be paid. Sometimes, they may pay part of the claims and in worst-case scenarios, you are not getting successful claims process.
These things are almost normal in the health insurance sector and you should be acquainted with the factors that can lead to the denial of claims. They include:
Wrong ICD-10 Coding
If your doctor inputs the wrong ICD-10 code for a particular diagnosis, your claims application will be rejected. Your healthcare provider must of necessity link the right ICD-10 code with the appropriate diagnosis.
This is why you must be acquainted with the provisions of your health insurance policy. Certain treatments are not covered in your insurance policy and when you receive those treatments, your insurer is not liable to pay any claims to you.
Missing Paperwork and Information
I am saying this again, for a tiny bit of information not provided, your claim application may be rejected. As an issue of top-most relevance, ensure you are not leaving out any piece of information whatsoever nor paperwork to be on the safe side.
Unnecessary and Experimental Treatments
Certain treatments are considered to be unnecessary and experimental. To insurance companies, they believe such treatments do not make a patient well and with a good claims adjuster, your claim would not see the light of the day.
Expensive treatments, diagnostic studies, and heavy surgical operations require prior authorization from your health insurer before any medical care should be given. But this is not always possible as one can be in life-threatening conditions requiring urgent attention.
This is not so much of a problem as it can be appealed.
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Now you have it – how to file a health insurance claim.
When all your paperwork is ready, nothing stops your application. Do well to check the factors that lead to denial. Cheers to a successful claims process.