Filing a Claim with Your Private Health Insurance Plan: A Step-by-Step Guide

When you or a loved one is in need of medical care, the last thing you want to think about is filing an insurance claim. But understanding how to file a claim with your private health insurance plan is essential for getting the coverage you need. By definition, a health insurance claim is what a doctor submits to his insurance company after providing a procedure or service to get paid. So if you find that you need to file a claim, how will you know if you're doing it correctly? Let's take a look at the steps involved in filing 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, schedule an appointment, get a quick exam, and you may be prescribed antibiotics. You pay your co-pay and they send you on your way. The doctor's billing department fills out a health insurance claim form, usually a CMS-1500, also known as a pink sheet because of its distinctive color.


They send it to the insurance company and that's the last thing they hear about it. Well, that's how it usually works. Depending on your health insurance plan and the type of services you receive, you may have to file an insurance claim form yourself.

Make a copy of any documents you receive and place them in a file marked specifically for your claim. You'll want to keep everything in one place so that you can easily find anything you need later on. Insurance claim forms are sometimes denied or lost, and are subject to all kinds of mischief. Being able to view your documents quickly and easily is a lifesaver. The first step is to call your health insurance company and tell them that you are about to submit your health insurance claim form.

Review all the documentation you have with them and ask if there's anything else you need. Ask how long you should wait for your claim to be paid and mark that date on your calendar. Once you have all things in order, it's time to file the claim. Most of the time, you can do it online. However, sometimes you may have to send a claim form by mail.

They should be able to guide you through the shipping process. Now there's nothing to do but wait. Keep an eye on your calendar and keep in mind the date of the claim indicated to you by your insurance company when you called. If you don't receive payment for your claim within the established time frame, contact your insurance company and let them know. When you talk to someone, be sure to write down the date, time, and full name (or names) and positions of the people you're talking to to create a paper record, which you may need if more problems arise with your claim. When selecting a health plan, consider factors such as premium cost, out-of-pocket costs (deductibles, copayments and coinsurance), provider networks and coverage for services such as prescription drugs or mental health care.

A Gold or Platinum plan with a higher premium and lower out-of-pocket costs can save money in the long term for someone who has serious medical problems and who expects to receive many health care services during the year. If someone is relatively healthy and doesn't expect to receive many health care services, a Bronze or Silver plan might be a good option. If possible, it's wise to set aside funds to cover cost-sharing when medical care is needed. PPO benefit plans allow policyholders to choose between a network of doctors, hospitals, and other contracted health care providers, or to use an out-of-network provider and be required to pay a greater part of the cost. PPO plan members can generally see specialists without prior referral or authorization.

HMO benefit plans require that policyholders seek health treatment only at designated hospitals, doctors, HMO centers and other network providers, except in case of emergency. Some HMO plans also require a referral from a preferred care provider (PCP) to obtain prior authorization to see a specialist. All health insurance plans offer guaranteed renewal of coverage; meaning members can stay in the plan as long as the insurance company continues to offer it.eHealth can also help manage an incorrect health insurance claim. No person applying for health coverage through the individual marketplace will not be deterred from applying for benefits; nor will they be denied coverage or charged an additional premium for their health status, medical condition, experience in mental illness claims, medical history, genetic information or health disability. They verify that the claim is complete, accurate and that the service is covered by your health insurance plan. Reimbursements mean that members must pay for care in advance; if their health insurance plan covers medical treatment; they can submit a request for reimbursement through their insurance plan.

From Charlotte to Raleigh; from Asheville to Wilmington; explore these North Carolina health insurance options and many more that might be available now. Health insurance can be confusing especially if someone has never addressed it before so it's normal to have several questions. The cost of health insurance (premium) can change from year to year as can the plans offered by each company. By understanding how filing an insurance claim works with private health plans; members can make sure they get all of their medical expenses covered without any hassle or confusion.

The monthly premium is usually lower but members pay more medical expenses out of pocket before their insurance company starts paying its share.

Tommy Gair
Tommy Gair

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