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How to File a Medical Insurance Claim

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The lowdown...
  • Medical claims are formal requests made for payment of services like doctor visits, testing or medications and should be accompanied by an itemized list of all services and products used
  • There is a limited amount of time for you or the provider to file a medical claim
  • Paying attention to details and having all information correct will help keep the medical claim from being denied
  • Pay close attention to the time allowed and procedure for filing an appeal if your medical claim is denied
  • Use the correct forms and include the specific documents requested to properly submit a Medicare medical claim.

What is a medical claim?

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A medical claim is an itemized list of medical services submitted to an insurance company claims processing center for payment or reimbursement for plan covered services. Normally the healthcare provider will send in the claim, but there are times when a patient is required to for reimbursement, such as seeing an out-of-network provider. Some of the cost may be covered, but it depends on the policy.

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Most insurers and providers have an agreed upon amount that is paid for specific services. Rarely is an insurance company going to pay 100 percent for any covered service, but healthcare providers make their income over long-term relationships with insurers and patients. You may not receive any reimbursement for services if you are still covering an annual deductible amount.

What will you need from your doctor?

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Filing an accurate medical claim will mean getting an itemized list from doctors and pharmacists for all services, medications, and tests done in relation to the medical issue at hand. Make sure that all prescriptions are listed and what they are for. You will have to attach the original itemized receipts to the claim form and mail them to your insurer.

Make sure you include receipts from places like physical therapy services, laboratories, and hospitals. Medical mobility equipment is often covered by health insurance. Include the monetary amounts spent in this arena as well. Any service, medication, or medical professional that assisted in the diagnosis and treatment of your ailment needs to be included with your claim. Write your name and social security number at the top of each receipt in case they get separated from the paperwork.

How much time is there to file a medical claim?

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Most health insurance companies need to have a medical claim filed by no later than the end of the calendar year in which services were received. It can vary but should be clearly stated in your policy contract. You need to research this, or cal your insurer to make sure you have enough time to file the claim. You can and will be denied if it is beyond the agreed upon claims filing deadline.

Should the doctor file the claim?

If you are using the health services of an in-network provider, they should be the ones filing the medical claim. It can normally be done easily electronically from their office. It would be highly unusual for a provider in your network to demand that you file the claim.

Using an out-of-network doctor, or seeing a specialist may require paying for the service initially, filing the claim and getting at least some reimbursement later.

It is common in cases where you want to keep the same doctor, but they are not in the network for your insurance plan. This can happen when doctors shuffle out of one network and into another. Your only option is to pay a higher amount to retain their services, file a claim for reimbursement of part of the costs, or switch to an in-network doctor.

How to Keep a Medical Claim From Being Denied

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Little mistakes with information, errors in numbers or spelling of names can all be reasons that a medical claim gets denied. It may have nothing to do with the medical services received. A little care and attention to detail can keep your claim from being denied.

– Make Sure Everything is Spelled Correctly

Names of patients, treatments, and doctors can all be critical. Make sure everything is spelled correctly before submitting a medical claim.

– Check Your Numbers

Incorrect social security numbers, addresses, and procedure codes can all result in a denied claim. Take the time to make sure all of this is done right the first time.

– Time Is Critical

Understand the time limit you have to file a claim and follow it. Allow plenty of time for the claim to be received and for the insurer to begin the processing. Pushing the envelope of the deadline will not benefit the situation at all.

– Get Services Preauthorized

You will know if it is worth filing a medical claim if you seek preauthorization and are turned down. Some procedures and services require preauthorization to show medical necessity. Without this, the claim will be denied.

– Is the Service or Procedure Covered?

There are a few procedures and services that some insurance companies will not cover. These are usually elective services that are not medically necessary. Cosmetic procedures are rarely, if ever, covered by a standard health insurance policy.

– Know the Bill Will Come Before the Claim Is Paid

Do not have a heart attack about a bill from the medical service or provider that comes to your door. The bills are often generated well ahead of any payments received by an insurance company. This is not a sign that your claim is being denied.

How to Appeal a Denied Medical Claim

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All of the care in the world and making sure that the paperwork is done correctly may not keep a medical claim from being denied. You have the right to know why the claim is being denied and the specific process it takes for an appeal with your particular insurer. You can usual file a formal internal appeal for the insurer to self-review the claim. You can also request a third-party look at the claim denial with an objective view. Be sure you follow the time given for filing an appeal.

Medicare and Filing a Claim

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Having a file a medical claim for Medicare should not be a common activity. There may be times that claims are filed in an untimely manner, leaving you responsible for paying medical bills. If your provider is slow about filing, it might be in your best interest to file the claim instead. There is one calendar year from when medical services were received to file the claim for payment.

You can find links to the appropriate forms needed for filing a Medicare claim here. Follow the instructions for the type of claim you are needing to file. You will send the completed form with all detailed receipts, itemized bills and supporting documents with the claim form. You will also need to write a letter explaining why you are filing the claim, rather than the provider.

Check With Your Insurer for Their Specific Claims Filing Process

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There is no standard for filing medical claims that every company follows to the letter. In order to ensure it is done right, contact your insurer to learn about their health insurance claim process. They might have an online form available, which will cut down on some of the time. You will still need to send in the documents needed that show the amounts paid, or owed to a medical provider.

Be as thorough with spelling, numbers and making sure that all information is correct in an online format. Gather all of the information together in one folder, which will keep you from forgetting anything. Try to not leave any areas of the forms blank. If they ask a question, give them a credible and reasonable answer. Save any confirmation information you receive in regards to filing your medical claim electronically.

Filing a medical claim is not a typical activity for most people, but it is important to know how this is done correctly. Contact a health insurance expert if you have any questions about filing a claim today!

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