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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