When you visit a health provider, the top priority is to get healthy or stay healthy. The last thing you want to worry about is mounting medical bills or the logistics of your medical insurance plan. Understanding how the medical insurance claims process works is essential to know what to expect when it comes to claims coverage.
Today we’re going to look at what happens to the claim and how to successfully submit your claim, so you receive the best reimbursement for your medical bills.
What is a Medical Insurance Claim?
Simply put, a medical insurance claim is what the doctor submits to your insurance so they can get paid. It shows what medical services and treatments were provided to you or the other beneficiaries on your policy. When claims are denied or not fully covered, the policyholder is held liable for the medical costs associated with treatment.
How Does Claims Processing Work?
- After your visit, either your doctor submits a bill to your insurance provider for any charges you didn’t pay in the office, or you submit the claim for any services you received.
- An insurance claims processor will review the submitted claim and check it for completeness. They will determine if the services provided were covered under your plan.
- The claims processor will verify important information, such as your copay and how much of your annual deductible and out-of-pocket maximum you’ve paid on the medical policy this far.
- If it’s determined service is covered by your medical insurance plan, the insurance company will pay the claim on your behalf. Coverage can range from partial to complete (depending on your benefits). You will be required to pay any remaining balance.
What Happens After a Medical Claim is Processed?
After your claim is processed, you will receive an explanation of benefits (EOB) that details how your medical insurance is covering your recently submitted claim. Your doctor may send you a final bill for services outlining what you owe. Make sure you do not mistake this for your EOB. Make sure you pay your healthcare provider as soon as possible. If you believe an error was made on your EOB, contact your insurance provider directly.
Tips for Submitting a Successful Claim
The first step to submitting a successful medical insurance claim starts with preauthorization. Preauthorization is when you or your doctor call the insurance company to verify a specific medical service is covered under your plan. Preauthorization will also tell you how much, if any, your out-of-pocket cost will be.
Typically, your provider will submit your preauthorization and subsequent claim after services are provided. In rare cases, when you visit a doctor outside of your plan, you may be required to submit the claim yourself. Here are some steps to ensure your claim is processed smoothly:
- Verify your treatment claim is covered by your insurance plan
- Use the claim form from your benefits plan
- When filing by hand, be sure to write legibly
- Include all necessary information, including procedure codes (you can ask your doctor for these codes)
- Include pre approval (when necessary)
- Review all the information before filing
- File your paperwork promptly, and preferably online for faster processing (if applicable)
- Make a copy for your personal records
- All the original documents including Bills, reports to keep ready in hand as it may be requested in the future by the Insurance company for any further investigation.
Filing a claim with your insurance provider can be a frustrating process, but it doesn’t have to be. At Petra, we understand all things medical insurance. Whether you are looking for a new medical insurance policy or looking to add more coverage to your existing policy, we can help you determine which services are covered under your medical insurance policy.