It all starts with filing a claim.

Step 1:

To receive your health insurance benefits, you or your doctor must file a claim with the insurance provider.

If your doctor is in the plan’s network, his office will generally file the claim for you.  If you see a doctor outside the plan’s network, you will probably have to file the claim yourself.  Some providers, especially mental health professionals, are outside of any insurance plan, in which you will always have to file the claim yourself, and expect to pay more out-of-pocket.

If you do have to file a claim yourself, don’t put it off!  Many plans limit the length of time after receiving services that you can file a claim.  Some time limits are as little as 30 days after your appointment.

Your Benefits Summary document should include instructions on how to file, along with copies of claim forms or details on how to obtain them (such as downloading them online). The back of your insurance card will likely have a toll free telephone number for member services that you can call for assistance, as well.

Check to see what kinds of documentation you must provide with your claim form.

For example, you may need a copy of:

  • Your receipt from the doctor’s office.  Make sure it includes your name, the type of visit and diagnostic code.  A credit card or receipt for payment is not enough.
  • Your referral to a specialist or for a test.  Make sure that your doctor’s name, address, telephone number and provider number are clearly legible on any documentation you submit to the insurance company.

Be sure to keep a copy of everything you submit and record the date you mailed the claim.  If you speak to anyone at the insurance company about the claim, keep detailed notes, including names, dates and times.

Step 2:

The insurance company will send you an Explanation of Benefits (EOB) form detailing their payment, either to you or directly to the doctor (remember those forms you signed assigning insurance benefits to the doctor?  That is how they get paid directly).

Compare the EOB to your copy of the submitted claim to make sure that you have been fully covered for the visit or procedure.

Make sure you understand the breakdown of how the claim was paid:

An EOB will usually include:

Claim Number, Date Paid, Date Claim Received, Date Claim Processed

The provider name – doctor, hospital or other

Whether he or she is a preferred or out-of-network provider

The Type and Dates of Service

Submitted Charges – full amount that would be charged to a non-insured person

Plan Allowance – how much your plan is willing to pay for the contracted service

Remarks if applicable – usually with numeric codes explaining some aspect of how the claim was calculated

Deductible – the amount that you must pay toward meeting your annual deductible if it has not yet been met

Co-Insurance or Co-pay – the percent of the service that you are responsible for

Medicare or Other Insurance payment if applicable

What The Insurance Paid – final amount sent by insurance to the doctor

What You Owe the Provider – combination of Co-Pay (your per visit charge) and Co-Insurance (percent of the procedure you must pay)

Step 3:

If all goes well, the amount your doctor bills you will match with the EOB’s “Amount You Owe the Provider.”

That means, in effect, that the insurance company and the doctor agreed on payment and your account was correctly credited with the insurance benefit payment and your in-office co-pay.

Step 4:

If the amount your doctor says you owe and the insurance company says you owe the doctor do not match, you have a problem.

At that point, call both the doctor’s billing office and your insurance company.  Many times this is simply a clerical, billing or coding error.  Your insurance might tell that the doctor coded wrong and give you the right codes to submit to your doctor’s billing office.  The billing office will then resubmit the corrected claim.

See also:

“Understand Your Insurance Coverage”

“Glossary of Important Insurance Terms”

“What to do with a Denied Claim”