Filing a Health Insurance Claim

January 17, 2024

When you see a doctor for care, their team usually handles filing the claim for you. This claim alerts your health insurance company that you have received care and requests reimbursement for the services. In some cases, you can file a claim yourself to receive money back after paying for healthcare.

No one wants to file a health insurance claim — with so much terminology, it can get confusing fast. But don’t worry. Since most doctors file claims for you, it’s unlikely you’ll have to do this on your own often. If the event does arise, this guide will help you navigate filing a health insurance claim with confidence.

When Do I Need to File a Health Insurance Claim?

In many cases, nothing! Health insurance claims are usually filed by a healthcare facility’s billing department. In many cases, you never even see a health insurance claim because your provider’s office submits it on your behalf.

In the event that a facility is not in your network, you may have to file a claim yourself. Finding out you have to file a claim yourself may make you nervous, but don’t worry. The process is relatively straightforward once you understand how it works. Let’s cover it step by step.

How Do I File a Health Insurance Claim?

Filing a health insurance claim is not as complicated as many people fear it will be. In most cases, all you need to do is get the right form, fill it out, and send it to your provider. Some health insurance providers also allow you to file a claim electronically online, which makes the process even easier.

The general process for filing a health insurance claim is:

  • Getting the claim form. You will need the form from your company’s website to start the claims process. Most providers have digital claims filing processes today, so you should be able to do this without a printer. If not, then you can download and print the claims form to get started.
  • Fill in the proper information. You will need your insurance policy number, the name of the person receiving treatment if it is not you (for example, a spouse or child), and the reason for treatment, along with details about where you received treatment.
  • Create an itemized list of services. Your insurance provider will want to see receipts for services you paid for. Provide any documentation you have, along with an itemized list of services such as lab work, exams, medications you received, or healthcare procedures the doctor performed.
  • Make copies. Save a PDF of your claim, or make a copy for your records.

What Do I Need to File a Health Insurance Claim?

Before you can file a health insurance claim, there is some important information you will need to have on file. Keep this list handy so you can easily prepare for filing your claim without stress.

  • ICD-10 code. Every claim must have an ICD-10 code for your diagnosis to be accepted by a provider. You can Google the ICD-10 code for a condition, or you can ask the healthcare provider for it. Make sure that you have this to avoid having your claim rejected.
  • Itemized bill. It’s important to have a clear list of services and treatments you receive with their individual price. This tells the health insurance company how much you paid and how much they should reimburse you based on the terms of your policy.
  • Policy information. Make sure you have your health insurance policy number, member number, or group plan number.
  • Provider information. In addition to information about you or your dependent, you will also need information about the provider, such as their name and address.

What to Do If Your Claim Is Denied

Your health insurance company just denied your claim, but don’t panic. This can happen for many reasons, and you are able to submit another claim to seek reimbursement for services or treatments you paid for.

Claims are commonly denied due to inaccurate information — did you misspell the provider’s name? — and faulty or absent ICD-10 codes.

Sometimes, you have to get permission from your insurance provider before a certain type of procedure in order to be covered. If you’re undergoing a surgery or major diagnostics test like an MRI, biopsy, or endoscopic procedure, make sure you contact them first.

If there was an urgent situation that impacted your ability to get approval before treatment, this is okay. You can appeal the denied claim by providing further information.

The only time you cannot appeal a claim is if the treatments you’re requesting coverage for are not on your plan or they were elective procedures. Elective procedures are treatments that you may benefit from but are not considered medically necessary, such as plastic surgery or complementary treatments such as reiki, chiropractic care, massage therapy, or acupuncture.

If your claim is denied, make sure you have all the documentation on-hand before contacting your insurance provider. Be sure to provide as much support for your claim as possible in hopes of having your costs covered.

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