Health insurance claim

What is a health insurance claim?

A health insurance claim is a request made for direct payment or reimbursement for medical services that an insured person has obtained. Health insurance benefits or payments are obtained after the insured submits a claim to their insurer. Before making a claim, you need to know the procedure for filing one, and the documents and information required to file it.

Deeper definition

The first step in receiving health insurance benefits is you or your doctor files a claim with your insurance provider. If the doctor is in your insurance plan’s network, the doctor’s office will usually file the claim electronically on your behalf. If your doctor is outside of your insurance plan’s network, you may have to file the claim yourself.

If you have to file your own paperwork, the best place to start is to visit your insurer’s website. Many insurance companies allow insured individuals to log in to their health insurance plan portal online. Ask your employer if your workplace health plan provides this option. If you have a private health care plan that is not provided by your employer, contact the insurance company directly to find out how you can access its services online and help you set it up.

It is important to get an itemized bill from your medical provider and all the billing receipts before you file your claim. The itemized bill will list all services rendered by your doctor and the cost of those services. It is advisable to make sure your medications are clearly listed in the itemized costs.

Key information that you need to provide on the claim form includes:

  • Your insurance policy number, member number, or group plan number.
  • Whether you received the services yourself or if they were provided to a dependent or spouse.
  • Whether you have dual coverage or co-insurance.
  • Your reason for visiting the doctor.

One of the greatest advantages of submitting health insurance claims online is the fast processing of payments, which can take as little as 24 hours for approval. When you fill out your claim form online, there is a good chance that you will immediately find out what portion of your claim is covered, the applicable co-insurance clauses, and any deductibles.

Health insurance claim example

When you set up an online account to manage your health insurance plan and file your claims electronically, you get immediate access to the kind of benefits and refunds you will receive and access to any expenses that you may have to settle out of pocket. By initiating your health insurance claim online, you also get to see whether your insurer has received the documents submitted, the claim-processing status, and when payment will be issued or whether it has been paid.

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