Think You’re Covered? Surprising Exclusions in Common Insurance Policies
It’s also a good idea to read over your employer’s ERISA booklets, which will give you a better understanding of your rights and the processes for handling group health insurance claims. This is especially important if you’re filing a claim for benefits from an employer-sponsored plan. These booklets will also help you to understand how deductibles and co-payments work with your particular policy, as well as any other out-of-pocket costs that may apply.
For example, if your claim was denied because the service wasn’t medically necessary, you will need to document this with a letter from a healthcare professional, including their name, license number, date of appointment and the diagnosis or treatment given. This must be included with any other documents you submit to your insurer in order for an appeal to be considered.
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Filing Your Claim
Health insurance claims are an
intricate part of a patient’s healthcare journey, from the act of submitting
them to the deeper processes within an insurance company. If done correctly,
they can expedite a patient’s reimbursement and reduce their out-of-pocket
expenses. However, if a claim is mishandled, it can be an expensive or lengthy
process for both the insurance provider and the patient. The most important
thing to remember when filing a health insurance claim is to do your homework.
Review your plan’s Summary of Benefits and Coverage and claims procedure
booklet before submitting any paperwork. This will ensure that you meet all the
requirements and are eligible to receive coverage for your care.
Depending on the type of care you
received, the first step in the filing process is to get an itemized receipt
from your medical service providers. The bill will list all the services you
received, their cost and a special code that your insurance company needs to
process your claim. The receipt will also provide information like your
insurance coverage, copay or deductible amounts and any outstanding balances
you must pay to the healthcare provider.
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Once the receipts are ready,
contact your insurance company and request a claim form. Fill out the required
information and submit it with the necessary documentation attached. Typically,
the insurer will have a maximum allowable waiting period of 72 hours to 30 days
to decide on your claim. This timeframe may be extended if the insurer requires
more details or additional information to make a decision.
After your claim is processed,
you will receive an Explanation of Benefits (EOB) from the insurer. This
document will detail how your claim was paid, including the amount your
insurance company paid to the healthcare provider and any portion that remains
outstanding on your account. Review the incurred charges to confirm that they
are accurate and compare them to your final bill from the doctor to ensure all
charges have been covered by the insurance company. If your claim has been
denied, understand the reason why and consider filing an appeal.
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Consider your family’s medical
history and any ongoing health issues. Do they have a chronic illness that
requires regular doctor visits and/or prescription medications? What about
upcoming medical procedures or treatments, such as fertility treatment or a
knee replacement? Evaluate your family’s preferences for network coverage, as
well. Do they prefer to work with a certain type of doctor or hospital? Make
sure your preferred doctors and hospitals are in the plan’s network.
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