If you've filed a claim with your private health insurance plan, you may be wondering how long it will take to be processed. The answer depends on the type of claim you've submitted. If you've filed an electronic claim, it may be paid within two weeks. However, if an error is found in the claim, it could take much longer.
If the claim is filed on paper, providers should expect wait times of around 30 days. Once your request is processed, you will receive an Explanation of Benefits (EOB) that details how your plan paid for the care you received. You may also receive a bill from your doctor during this period for any fees that you or your insurance company haven't paid. Unfortunately, there are times when an insurance company doesn't pay a claim as quickly as you would like. Whether it's a prior authorization requirement or a medical coding error, we may all have to deal with a delayed insurance claim.
Knowing how to properly challenge a decision to pay a claim is key to maintaining your sanity and your financial health. After receiving the formal request for reimbursement from the policyholder, insurance companies review the health insurance claim, check for errors and inconsistencies, and confirm that the medical services listed match the medical and diagnostic codes indicated on the form. Assuming that the insurer does not find any problem with the policyholder's claim, they will proceed to reimburse the policyholder the amount they paid in advance and out of pocket for medical care. Unfortunately, health insurance companies can sometimes be slow to process health insurance claims. In some cases, the delay in a health insurance claim is due to the insurer investigating a claim and deciding that it is not within the scope of the health plan's coverage. In other cases, delays are the result of a lack of communication between providers and insurers due to each health plan having its own billing guidelines and internal coding procedures. If your retroactive refund takes longer to process than expected, most delayed claims are not due to bad intentions on the part of the insurer but are instead due to coding confusion or a clerical error.
If you submitted a health insurance claim form months ago and still haven't received a response or payment, the first step is to find out why there was a delay. If the customer service representative isn't cooperating or helping you, ask to speak to their supervisor. If your insurer's customer service representative offers to make an adjustment to your bill, ask them to confirm their offer in writing (or by email). No one wants to know that their request for payment for care they've already received has been denied. However, there are steps consumers can take to maximize their chances of successfully filing a health insurance claim appeal and recovering what they spent on care. Contact your insurer on a regular basis to check the status of your delayed insurance claim.
Be persistent, calm, and explain that you intend to continue with the problem until it is resolved and paid. The payment of a late claim can take many months to resolve so call your insurer often and take note of every call. The law also specifies that health insurance companies cannot put their own financial interests before those of their insured. Whatever the situation, a delay in payment, especially in the form of health insurance reimbursement, can be both a minor hassle and a financial burden. If you're having problems with your current coverage, we can help you look elsewhere. If your delayed claim becomes denied, you can choose to appeal.
Our mission is to provide information that helps ordinary people make better decisions about buying and maintaining their private health coverage. If you're not satisfied with your health insurer's review process or decision, call the California Department of Insurance (CDI). For help with Medicare plans, call 888-391-5203. For other plans, call 888-380-0672. Our editorial team is comprised of industry professionals and experts in the ACA, private health insurance markets, and government policies. If you are having difficulty accessing our website or need help with its functionality, please use one of the contact methods listed above.