When you or a loved one gets sick and needs medical attention, the last thing you want to think about is filing an insurance claim. healthcare can be complicated and full of jargon, and there is often a lot of paperwork involved. If you don’t dot your i’s and cross your t’s, your insurance company may deny your claim.
So if you find out you have to file a claim, how do you know if you’re doing it right? Okay. take a deep breath. Let’s look at how to file an insurance claim form.
how to file an insurance claim form
When you get medical care, you usually don’t even see the claim. For example, if you have a sinus infection, call your doctor, make an appointment, get a quick exam, and maybe get a prescription for antibiotics. you pay your copay and they send it on its way. the doctor’s billing department fills out a health insurance claim form, usually a cms-1500, also known as a pink slip due to its distinctive color.1 they send it to their insurance company and it’s the last they know.
well, that’s how it usually works. Depending on your health insurance plan and the type of services you receive, you may need to file an insurance claim form yourself.
Here’s a scenario: You and your family are headed to another state for a long weekend of skiing. one day while going down the slopes you hit that tycoon who was going a little too fast. you annihilate yourself and break your leg. After a quick ambulance ride to the ER, you get an X-ray, a cast, and a pair of crutches.
Depending on your health insurance plan and the type of services you receive, you may need to file an insurance claim form yourself.
oh, and you also get a giant bill because the small town hospital is out of your network and won’t work with the insurance you have three states away. You will need to submit a health insurance claim form. this is what you need:
1. claim form
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Your insurance company should have a health insurance claim form on their website. this will be a special claim form specific to your health plan. They will probably have a way to file the claim online, which is nice. but you should also be prepared to print the claim form and mail it. here are some things you may need to include in the form:
- your insurance policy number, member number, or group plan number
- the name of the patient receiving medical treatment (you, your spouse, your child, or anyone covered by your plan)
- whether or not you have dual coverage or coinsurance
- the reason for treatment (such as injury, illness, or preventive care)
- laboratory tests such as blood tests or urine tests
- radiology tests such as X-rays, MRIs, and CT scans
- medicines dispensed
- cardiovascular tests such as EKGs and echocardiograms
- durable medical equipment such as crutches or braces
- Coding Errors: Every diagnosis that a medical provider determines you need has what is called an ICD-10 code (abbreviation for International Statistical Classification of Diseases and Related Health Problems). , 10th revision). the icd-10 code is used to bill and track diseases and treatments.2 if a provider bills for a treatment or procedure that is not linked to a particular diagnosis, it will be denied.
- Lack of prior authorization: Some generally large and expensive treatments, such as surgeries or certain diagnostic tests, such as MRIs or colonoscopies, require that the provider obtain authorization from your insurance company before that they are made. . many times this is impractical or impossible, usually because it is an urgent situation and there is no time to obtain authorization. you can always appeal to these.
- Missing or incorrect information: This is another of the most common and usually involves missing documentation, such as a medical report. that is why it is important to collect all the relevant data.
- The treatment is considered medically unnecessary or experimental: Insurance companies may deny a claim because they don’t believe the treatment is really necessary for the patient to feel well. surgeries to correct deformities such as a deviated septum or varicose veins are common procedures that may be denied. A claims adjuster may view the claim and deny it as a “cosmetic” procedure not normally covered by insurance.
- the treatment is not covered by your plan: read your policy carefully. Depending on your policy and level of coverage, some treatments may simply not be covered.
If you’re injured on the job and covered by workers’ compensation, you may have to fill out a lot of special paperwork and go through a different insurance company than your normal health insurance company. You’ll want to talk to your human resources representative or consult an attorney who specializes in workers’ compensation. This is also true if you are injured in a car accident or due to someone else’s negligence (such as slipping and falling on a wet surface inside a business). these claims can get really complicated, and it’s nice to have someone on your side.
2. an itemized invoice and receipts
this is important. You absolutely must get an itemized bill from your provider. It should list all the services your doctor provided and include things like:
In other words: if the doctor bills you, you must include it on the list. each element must be on a separate line and must include the icd-10 code (more on this below) for each procedure.
3. copies of everything
Make a copy of each document you receive and keep it in a file marked specifically for your claim. you’ll want to keep everything in one place so you can easily find everything you might need later. insurance claim forms are sometimes denied or lost, and are subject to all kinds of shenanigans. so disputes may arise. being able to quickly and easily refer to your paperwork is a lifesaver.
once you have all your ducks in a row, it’s time to file the claim. most of the time, you can do it online. but sometimes you may have to mail a claim form. contact your insurance company. they should be able to guide you through the submission process.
Make a copy of each document you receive and keep it in a file marked specifically for your claim. you’ll want to keep everything in one place so you can easily find everything you might need later. insurance claim forms are sometimes denied or lost.
what to do if your claim is denied
okay, you’ve done everything right. you’ve dotted your i’s and crossed your t’s, shipped everything and talked to customer service. But a couple of weeks go by and she gets an explanation of benefits form saying her claim has been denied. Or maybe your insurance company approved part of the claim and paid part of it, but denied part of it.
remember to breathe! it’s okay. Do not panic. this happens much more often than you think. There are many reasons insurance companies deny claims. These could include:
So what do you do if a claim is denied? there is always an appeal process. just make sure you have all your records (including documentation of any phone calls) in order. If you are documenting a phone call, include the date, time, and a reference number (if available). always get the name of the person you talked to.
If your insurance company denies your claim because it is deemed not medically necessary, you will most likely need to involve your health care provider. Most insurance companies have a medical professional (such as a doctor or registered nurse) who determines what is necessary and what is not.
Your doctor may set up what is called a peer review. Sometimes called “doctor-to-doctor,” a peer review involves your doctor talking with the insurance company’s doctor to explain the medical necessity of the treatment or procedure. always request one of these if your claim is denied for this reason.
You’ll also want to make sure you keep track of the date. most insurance companies have a deadline for filing appeals. if your appeal is too late, they may refuse to consider it.
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