It’s beneficial to understand the claims process so that it is less confusing if you have to go through the process. We want to help you by breaking down what a claim is, why you might need to file a claim, how long that process will take, what to do if your claim gets denied, and how National Benefit Plans can help you.
Understanding the claims process begins with recognizing what constitutes a claim. When an insured party has covered medical expenses or receives medical services the provider will submit the claim on your behalf, and it can be seamless. The provider will submit the claim to your insurance carrier to be compensated for the medical services you received. They would use your insurance card and typically submit the claim electronically using standard medical codes. They submit a formal request to the insurance carrier to receive compensation for expenses incurred. This process requires the proper codes and medical provider paying attention to detail. Once your bill is submitted to the Insurance Carrier the Insurance carrier will send you an explanation of benefits (EOB) showing you the total charges for your visit. The EOB relays all the important information regarding the entire process, including your claim number and summary of when and what care was provided. The EOB is not a bill but is a document intended to help you understand how much your health plan covers and what you will pay when you get a bill from your provider. If you have a balance after submitting the claim to the insurance carrier for services, then you can expect a bill from the medical provider.
It is in your best interest to use your health insurance as your primary payment method, so that billing is submitted to the carrier by the provider. It is important to be familiar with your policy, so you understand what is covered, your deductibles and copays. Typically using insurance offers the most cost-effective option, although this depends on your policy limits. In some cases, it might be possible to set up a payment plan or self-pay options. While not universally available, some providers offer self-pay options. For example, when my daughter needed braces, our dental did not provide coverage for the expense but were able to set up a cash payment plan that saved us money and provided the service. While not universally available it is always worth inquiring about this possibility and comparing costs.
If there is a situation where your provider is unable to submit the claim on your behalf, then you might need to do this yourself. The most common reason seen for an insured needing to file a claim is when a doctor or provider is out of the plans network. Other reasons to file your own healthcare claim might be due to international travel or specified care such as medical equipment. You could have out of network coverage at a higher cost, but it varies depending on the carrier and plan. When submitting a medical claim, specific forms can be found on your insurance carrier website, or our office can provide those for you. It is important to note that some carriers require medical claims to be made within twelve months of the date the medical service was provided. When someone incurs a severe illness, the medical expenses add up and it can feel daunting. We want to help you and be your resource. For over 30 years we have been helping insured with their medical billing and claim issues.
If for some reason your claim is denied, remember not to panic. There are several reasons why carriers deny certain claims, such as treatments that have been unnecessarily administered, incorrect or omitted information, billing the wrong provider, and failure to get prior authorization. We have helped many of our insured resubmit claims with multiple carriers in the past. The first thing we would consider is making sure the provider is submitting the claim with the correct policy number and to the correct carrier. We might need to see if any extra steps are needed such as requesting medical records or additional information. We would want to provide timely updates on the status of the claim. If the claim is still denied, then there is an appeal process. If choosing to appeal, the first appeal will be done internally by the carrier. The internal appeal will produce the carrier’s final decision. If further escalation is required, a second appeal, called an external appeal can be filed. The external appeal is submitted to the Department of Insurance and Financial Services (DIFS) via a form online. There is also an expedited external appeal option available for urgent care needs.
Claims are generally a private relationship between you and your carrier, but if you require help you can authorize our office to assist you with the claims process. The top priority for our independent agents is to secure the best rates and coverage for you, as well as ensuring that you understand all the specifics of your policies. If at any time you need assistance with your situation, feel free to reach out to your licensed agent or our office. We take pride in being a valuable resource for the insured providing services, guidance, and information. At National Benefit Plans, we are here to assist you throughout the entire claims process.
For over 30 years, NBP has been dedicated to the well-being of clients and the success of agents by always striving to do the right thing and caring for everyone as if they were family. We have offered the best national and local carriers offering top-notch, affordable healthcare coverage for individuals, families and groups, including supplemental Medicare plans.
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