Filing a Health Insurance Claim

Health Insurance Approved Form Showing Successful Medical ApplicationHealth insurance claims are health insurance in action. The very reason we buy healthcare in the first place is because we want coverage for our doctor visits, especially in the event of a critical health need.

When you use certain healthcare services, such as urgent care, emergency services and specialty healthcare treatments, you may need to file claims.

Filing a health insurance claim is usually not difficult. However, the claims process does not always happen quickly, and in some cases can result in a health insurance claim denial.

If you are looking for a new policy or a better customer experience, contact one of our independent agents in the Trusted Choice® network who specializes in healthcare coverage. Our agents can make sure you have the right health plan for your needs and can help your health insurance claims go smoothly.

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Common Reasons Why a Healthcare Claim Is Denied

  • Seeking treatment without authorization
  • Making mistakes in claim filing
  • Filing healthcare insurance claims outside time limits
  • Getting treatment or medical services not covered by the healthcare policy
  • Opting for medical procedures that are not necessary

When Should You File a Health Insurance Claim?

Insurance companies watch the bottom line and keep an eye out for fraudulent health insurance claims. To avoid having your healthcare claims denied, make sure the medical service, procedure or treatment you seek is recommended and authorized by your primary care physician or a doctor you have been referred to for care by your doctor or clinic staff.

The typical times when you may need to file a health insurance claim are when you are sick or injured, when you have a procedure done that your physician has prescribed, or a family member is sick, injured, or needs surgery. You may also need to file a claim if you need urgent care services outside of regular clinic hours.

Be sure to coordinate with your health insurance company representative before any care or procedure, whenever possible, to determine which aspects of your medical treatment are covered.

Types of Health Insurance Claims

  • Preferred Provider Organization (PPO)

Preferred provider organizations allow the healthcare policyholder to seek treatment from a preferred healthcare provider. When you are a PPO member and use services within your PPO network, your policy typically covers those expenses.

  • Health Maintenance Organization (HMO)

In an HMO plan, the healthcare policy covers only the treatment sought from accredited physicians, clinics and hospitals specified in the policy.

  • Group Health Insurance Plan

Any individual member of a group health insurance plan can apply for claims for a range of medical expenses. With group long-term health insurance plans, the members can also claim reimbursements for treatment sought for prolonged illness, cognitive disorder, degenerative conditions or other chronic health issues.

  • Claim Benefits

With some health insurance policies, you can use pre-tax dollars for medical treatment, medical costs and other healthcare expenses. A health reimbursement is arranged, and you can file a claim for reimbursements for any covered family member’s medical expenses.

Another common feature in group plans today is the Health Savings Account (HSA). With an HSA, the person insured can save money for medical costs and enjoy tax advantages as well. HSA plans are associated with high-deductible health insurance. Contact a local independent agent for additional information.

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Make Sure Your Claim Is Valid

A health insurance claim is simply the bill that you or your health provider must send in to your insurer for payment of the medical services rendered to you.

For example, if the bill for your care services is $100, you pay your share of $25 and the health care provider collects the $75 from your insurance company. Or if you are in a plan that allows you to use services outside of your network, you may need to cover the costs first and then submit the bill to your insurance company yourself.

When receiving healthcare services and filing claims, read through your benefits and coverage specified in your policy, or contact your insurance company to determine if your services are covered. Do not hesitate to ask questions or clarify the things that you do not understand. This will help you avoid guesswork about whether your insurance company will cover your health insurance claim.

As long as you understand your benefits and your claims are within the limits of your coverage, you should have no problem with the claims process.

What to Do With a Health Insurance Claim Denial

Health insurance denied photoIn the event your health insurer denies your health insurance claim, you have the right to appeal.

As per the Affordable Care Act passed in 2010, health plans are required to meet basic standards regarding processes of internal appeals and external reviews.

You have the right to know why your claim is denied. Your insurer has to tell you the reason for your health insurance claim denial or reconsider the claim. This is called internal appeal.

If the internal appeal does not change your insurer’s decision, you have the right to ask another party to review the decision of your insurance company. This is called external review.

Working with an Agent for Your Healthcare Needs

Our local independent agents in the Trusted Choice network who specialize in health insurance can find the right coverage for your family and help you understand your policy’s coverage. They can also assist with the claims process. Contact us today and get the right healthcare coverage for your needs and budget.

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How to File Car Accident Insurance Claims

Car accident wreckage photoIf you are wondering whether your car accident claims process will be more difficult to bear than the accident itself, the good news is that filing a claim is usually fairly simple.

By following a systematic approach and carefully recording what has happened, you can gather all of the information you need.

The following guidelines from our friends at Trusted Choice will help you ensure the process goes smoothly.

Check the Accident Scene and Get Emergency Help

Before you and the other driver contact your insurance providers to file automobile insurance claims, get your vehicle to a safe place and make sure everyone is okay.

If anyone is injured, call 911. The most important thing to do is ensure that any medical emergencies are taken care of immediately.

Next, contact the police to report the accident. They will be able to file a report and take down necessary information for your insurance agent.

Document Everything

There are many factors that go into a collision, some of which may not have been avoidable. Never admit you caused an accident. Do not blame the other driver either. Often it takes a police officer and/or an insurance adjuster to determine what happened and who is at fault.

The best approach is to document the accident. If possible:

  • Take photos of the damage to all vehicles involved.
  • Photograph the accident scene and any property damage.
  • Take photos of identifiers, such as intersections and addresses.
  • Gather accurate information from other people involved.
  • Take clear pictures of insurance cards, license plates and other identifying information.
  • By documenting the accident, you will be able to help prevent false claims from the other driver or others involved.

Accident report photoContact Your Agent

When an accident or theft occurs, it is important to file an auto insurance claim as soon as possible. Have your vehicle information ready, as well as details about what happened.

When you file an accident insurance claim, your agent will ask some basic questions that will ultimately pertain to your auto accident insurance settlement. For example:

  • Was anyone injured?
  • Where is your vehicle?
  • Does it need to be towed?
  • What happened?
  • Describe what happened as clearly as possible. Provide the police report numbers and insurance information you gathered from anyone else involved. If your car has been taken in for repairs, include the contact information for the repair shop.

How Do Auto Insurance Claims Work? >>