Health Insurance Claim Procedures

Health insurance claims are necessary in order to pay a health care provider or physician for services such as surgical procedures, patient examinations or medical tests. Unfortunately, the procedure can be frustrating for patients, especially if the health care provider does not help with the process. Instead, medical billers or health claims specialists can help patients with the process. They have the role of accepting or denying claims after evaluating them.

Filing a Claim

Filing a claim can occur in two ways: by having your physician’s office file a claim for you or filing a claim with your health insurance provider. The most common way of filing a claim is to have your physician’s office do it for you, according to the HealthQuote 360 website. However, some health insurance companies offer claims at affordable rates. Once the insurance company files a claim with your physician’s office, the claim shows a list of procedures and services you received during your visit. You can only receive a claim after paying your physician's co-pay.

The next procedure in health insurance claims involves an evaluation of your claim. The company reviews each procedure or service and determines whether it was medically necessary. Making sure that a patient’s information is credible, complete and correct is also important. Lastly, the company determines whether the physician requested a reasonable price for the listed procedures. Some patients are not aware that their claims can be partially paid for certain procedures and that they may receive a bill for the difference. When deciding on the appropriate physician, you should make sure that he is under your health insurance list of recommended physicians. Some plans may not require a list and allow you to choose whichever physician you want. This could mean that your health insurance may not pay the claim in full. You should also make sure any procedures your physician provides are reasonable by your health insurance provider before having them done.

After evaluating the patient’s information and listed procedures, the health insurance company may approve, partially approve or reject your claim. If the company denies a claim, it has the responsibility of informing your physician and sending you a letter regarding the reason for denial. You have the option of challenging the rejection by “protesting your health insurance company, filing a request for review or filing a request for review with your state’s department or your health insurance company,” according to HealthQuote 360. A claim may be denied because the physician’s office did not provide the proper code, the services may not be covered under your health insurance or the medical procedure was not medically necessary or experimental. For example, plastic surgery is an example of a procedure that health insurance companies may not cover. Issues for improper or incorrect codes can be resolved with a phone call to your health insurance provider.