Insurance Claims

Every time you go to a new doctor, you do the same thing: Fill out long forms with all your insurance information, then give your insurance card to the receptionist. So what happens next in the insurance process? How does a claim go through once the card is in the hands of the doctor's office?

Let's start with a simple definition. A health insurance claim is a bill for health care services that your health care provider turns in to the insurance company for payment. With many plans, when you go to the doctor for a routine checkup and your bill is $100, you pay a co-pay or coinsurance of $25 and your doctor bills your insurance carrier for the remaining $75.

Your insurance claim actually begins before you even make an appointment. Your insurance carrier is responsible only for paying benefits that are covered under your policy, so you should do some research to avoid being shocked when you settle up with your doctor or pharmacist. Don't hesitate to ask your insurance representative to clarify anything you don't understand. Read your policy thoroughly so you know what's covered. This is especially important when something comes up, like a diagnosis that requires treatment not covered in your policy.

After you've paid, your doctor sends your bill to an insurance claims processing center. The processing center gathers all relevant information from your doctor -- the patient information sheet, intake forms and the proper services documentation. These are compared to the insurer's explanation of benefits to see if the policy covers the services. If it does, your insurance carrier will submit payment for the remaining balance. If not, you are responsible for whatever balance is left after your co-pay.

That sounds easy enough, doesn't it? Most claims processes are smooth, but you may encounter some bumps in the road -- the dreaded denied claims. We'll find out what to do about those in the next section.