Customized Coverage: How to Tailor Your Insurance Policy Smartly
Health insurance claims can seem complicated. After all, they’re the path a healthcare provider sends to a private insurance company to request reimbursement for services rendered. It’s an important process because it ensures the doctor gets paid, the insurance pays covered benefits and you get billed for the remaining balance. However, this isn’t as easy as it sounds and many things can go wrong along the way.
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For instance, you might need to
submit a claim for out-of-network care. In-network providers usually handle
this for you, but if you’re seeing someone outside of your plan’s network, you
may have to file the claim yourself. Likewise, if you have an FSA account that
covers reimbursement for dependent care costs like childcare or elder care,
you’ll need to submit a claim.
A bill is an itemized list of
services and charges for those services that a healthcare provider sends to you
or your insurer after providing care. A claim, on the other hand, is a formal
request to reimburse for healthcare expenses, which you might have to pay
upfront and then seek reimbursement from your health insurance company
afterward.
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The claims process starts as soon
as you check in at a healthcare facility. In-network healthcare providers
generally submit medical claims for patients after each appointment, and they
may have a set window in which to do so to avoid missing deadlines and being
rejected. If they fail to submit the claim within this time frame, the
insurance company can reject it or ask the healthcare provider to submit it
again with new documentation.
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After the healthcare provider
submits the claim, the insurance company will evaluate it and pay the approved
amounts based on coverages. This is typically done in an EOB (explanation of
benefits) that lays out the list of charges, the amounts the insurance company
paid and the amount you owe to the healthcare provider.
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It’s important that all required
documents are submitted for each claim so it can be processed quickly and
accurately. If there are any errors or omissions, the claims process can be
delayed until those issues are corrected. This can be frustrating for both the
patient and the provider. For example, if physician notes, diagnosis
information and CPT or ICD-10 codes aren’t provided, it can cause the insurance
to flag the claim as unprocessable.
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