Navigating the complicated world of health insurance is a confusing process. It definitely doesn’t help that you have to manage insurance claims while you are also dealing with health issues that are the reason you visited the doctor in the first place. Understanding how the insurance claims process works can make the situation easier to handle and help you avoid any surprises.

Here are the basic steps involved in processing an insurance claim:

  1. Claim is Submitted:

    This part is usually pretty straightforward. You show your medical card to the doctor’s office upon arrival and the billing department at your doctor’s office will submit the insurance claim for you after your visit or medical procedure. If you do happen to visit a doctor outside your health insurance network, you may need to fill out the claim form yourself and your benefits will likely be reduced. This is why finding in-network providers is so important.

  2. Claim is Reviewed:

    Your insurance company or medical plan claims administrator will review the claim and your benefits coverage based on the plan you elected. Occasionally, additional information about your illness, injury, or procedure will be needed. You may receive a letter or call from the insurance company asking you to provide further details. Responding to these requests in a timely manner will help ensure your claim is paid promptly.

  3. Claim is Paid:

    Your insurance company will pay all or some of the claim depending on the coverage your plan provides for that particular procedure. Often you, as the patient, have some responsibility for payment, such as a co-pay, deductible, or co-insurance

  4. EOB is Sent:

    After your claim is processed, you will receive an Explanation of Benefits (EOB) from the insurance company. The EOB includes information about your medical procedure and what is covered by your plan.

  5. Final Bill is Received:

    Then, you will receive a final bill from your doctor. Always review the amount on the EOB and the amount on your doctor’s bill to make sure they match. If the amounts don’t match or you haven’t received an EOB from the insurance company, call the billing department at your doctor’s office and the insurance company to discuss the difference.

During processing, some errors may occur that you need to watch out for. Doctors may accidentally submit incorrect information on an insurance claim that can drastically change the outcome of the claim. When you receive your EOB make sure to double check all the information listed. If something seems off, reach out to the billing department at your doctor’s office and call your insurance company or medical claims administrator to get it straightened out.

Dealing with insurance claims is stressful. Participants on the Helpside Medical Plan have the added resource of our Client Success Team to help explain benefits and understand claims. If you have questions, reach out to us at service@helpside.com. Want to share this info with your team? Click the button below to to access a printable version of this information:

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This blog was written by Steve Anderson, VP Benefits at Helpside. Steve has helped small businesses manage their employee benefits for more than 20 years.