Health insurance can provide critical coverage for our doctor visits, whether routine or unexpected. When you use healthcare services, such as urgent care, emergency services, and specialty healthcare treatment, you may need to file claims to get reimbursed by your carrier. Fortunately, filing a health insurance claim is usually not difficult. However, the claims process does not always happen quickly, and in some cases, it can result in a health insurance claim denial.
If you're looking for a new medical insurance policy or a better customer experience, contact a local independent insurance agent. Your agent can not only help you shop and compare healthcare plans from multiple top-rated carriers, but they can even help file health insurance claims for you when necessary. But first, use our guide to filing health insurance claims the easy way.
When Should You File a Health Insurance Claim?
Health insurance companies keep an eye out for fraudulent health insurance claims. To avoid having your healthcare claims denied, make sure the medical service, procedure, or treatment you seek is recommended and authorized by your primary care physician or a doctor you've been referred to for care. Often, you may need to file a health insurance claim when you visit the doctor because you're sick or injured, when you have a procedure done that your physician has prescribed, or a family member is sick, injured, or needs surgery.
You may also need to file a claim if you need urgent care services outside of regular clinic hours. Further, in certain cases, you might need to file a health insurance claim to get partial or full reimbursement for a prescribed medication if you paid out of pocket for it initially. Whenever possible, coordinate with your health insurance company representative before any care or procedure to determine which aspects of your medical treatment are covered.
Understanding the Different Types of Health Insurance Plans
Whether your health insurance claim will be covered or not depends largely on the type of healthcare plan you have. Here are some of the most common health insurance plans purchased by consumers.
Preferred Provider Organization (PPO) Plans
PPO plans allow the healthcare policyholder to seek treatment from a preferred healthcare provider. When you use services within your PPO network, your policy typically covers those expenses.
Health Maintenance Organization (HMO) Plans
In an HMO plan, the healthcare policy covers only the treatment sought from accredited physicians, clinics, and hospitals specified in the policy.
Group Health Insurance Plans
You might be an employee of a company that offers group health insurance. Any individual member of a group health insurance plan can file claims for a range of medical expenses. With group long-term health insurance plans, members can also claim reimbursement for treatment sought for prolonged illnesses, cognitive disorders, degenerative conditions, or other chronic health issues.
Health Savings Accounts
Another common feature in group plans today is the health savings account (HSA). With an HSA, the insured can save money for medical costs and enjoy tax advantages as well. You can use pre-tax dollars for medical treatment, medical costs, and other healthcare expenses. Additionally, you can file a claim for reimbursement for any covered family member’s medical expenses. HSA plans are typically associated with high-deductible health insurance.
How to Ensure Your Health Insurance Claim Will Be Covered
A health insurance claim is simply the bill that you or your health provider must send to your insurer for payment of the medical services rendered to you. Depending on your healthcare plan and the conditions of your coverage, you may be entitled to receive partial or total reimbursement for your health services, medication, etc., if the claim is approved by your health insurance carrier. If you have a healthcare plan that allows you to use out-of-network services, you may need to cover the costs first and then submit the bill to your insurance company yourself.
When receiving healthcare services and filing claims, read through the benefits and coverage specified in your policy, or contact your health insurance company first to determine if your services are covered. Many medical offices today will do this step for you and provide you with a summary of your benefits before you see a doctor or start your treatment.
Don't hesitate to ask questions about any part of your coverage that you don't understand. This can help you avoid guesswork about whether your insurance company will cover your health insurance claim. As long as you understand your healthcare plan's benefits and your claims are within the limits of your coverage, you should have no problem with the claims process. An independent insurance agent can also file health insurance claims for you.
What to Do In Case of a Health Insurance Claim Denial
In the event your health insurer denies your health insurance claim, you have the right to appeal. As per the Affordable Care Act passed in March 2010, health plans are required to meet basic standards regarding processes for internal appeals and external reviews. In summary, you have the right to know why your claim was denied. Your insurer must tell you the reason for your health insurance claim denial or reconsider the claim. This process is called an internal appeal.
If the internal appeal doesn't change your insurer’s decision, you have the right to ask another party to review the decision of your insurance company. This process is called an external review. For further assistance with appealing a health insurance claim denial, work with your independent insurance agent.
Here's How an Independent Insurance Agent Can Help with Health Insurance Claims
Local independent insurance agents who specialize in healthcare insurance can find the right medical plan for your family and help you understand your policy’s coverage. They can also assist you with the health insurance claims process. Your agent can answer any questions you may have about the claims process, including when to appeal a claim denial from your insurer. And down the road, your agent can help you update your coverage or find a new policy when necessary.
