The Claims Process

It is very important for individuals with insurance to understand the claims process.  Most people think that their providers will always handle the process for them.  While this is true in many cases, it is critical to realize that providers are protecting their best interests.  Therefore, you may not get the full benefit of your health coverage.   Basically, you may pay more than you needed too.  

Keep in mind, understanding your insurance coverage is probably your most important role in the claims process.  Understanding the claims process alone does not prevent an individual from unnecessary healthcare costs.

What is a Claim?

A health insurance claim is a bill for your health services that your provider submits to your health insurance company for payment.   Let’s say you go to your doctor for a routine visit and have a test performed.  Your doctor will send a bill, with the charges for the services you received, to your insurance company.  The insurance company will review the charges,make necessary adjustments, pay for services, and alert your doctor how much you will need to pay on this claim.

It is necessary to remember that Co-Payments are to be paid at the time of service. 

The Steps in the Claims Process

There are multiple steps that need to be completed prior to a claim being paid.  The Claims Process is pretty straightforward.  The following are the basic steps needed to be completed for a claim to be paid. 

• Step 1 – An insured individual seeks medical attention from a healthcare provider.  A healthcare provider could be a hospital, doctor, therapist, pharmacist, laboratory, etc.
• Step 2 – The healthcare provider submits charges to the individual’s insurer using a health insurance claim form.  The picture on this page is a little misleading since most claims are submitted electronically.  A series of codes are used to provide insurance companies details about the services rendered and the diagnosis made on the individual.
• Step 3 – The charges (or claim) are recieved by the insurance company.  Each claim is dated and coded to ensure timely filing and payment.
• Step 4 – The charges are reviewed to ensure they follow the guidelines of the policy and a determination is made to the allowed charge and what will be owed by the individual.
• Step 5 – An EOB and a check (if necessary) are issued by the insurance company.  With today’s technology these are generally transmitted electronically to the healthcare provider.
• Step 6 – The provider reviews the information on the EOB, accepts necessary adjustments, and bills the individual for the remaining balance owed.

All health insurance companies have their own way of dealing with claims.  The above is a basic claims process that most individuals can expect to experience.