Understanding Health Insurance - Claims & Appeals

Filing a claim.
Understanding the claim process can help save you
time and avoid frustration. Here are some steps to keep
in mind when filing a claim.

  • Step 1: Know your health plan
  • Step 2: Talk to your medical provider
  • Step 3: Review your bill and EOB
  • Step 4: Problems and disputes

Step 1: Know your health plan

  • Does your health plan have network providers?
  • Does your health plan allow for out-of-network providers?
  • What are the deductible, copay or coinsurance amounts and when do you need to pay them?

Step 2: Talk to your medical provider

  • Confirm with both your health plan and provider that they're part of your plan's network.
  • Ask your medical provider how they collect your deductibles, copays and coinsurance and how they bill for services: 
    • Network providers bill the health plan directly.
    • Out-of-network providers don't have to bill the health plan, so you may need to do it.

Step 3: Review your bill and the Explanation of Benefits (EOB)

  • Network providers - Compare your bill with the EOB and pay what the health plan states is your responsibility to the medical provider.
  • Out-of-network providers - Contact your health plan to get claim forms and due dates.  You may have to pay the medical provider and wait for your health plan to reimburse you. If possible, ask your health plan about this process before you pay the medical provider.

Step 4: Claim problems or disputes

  • Review the coverage, benefits and appeals section in your benefits guide.
  • Contact the health plan and medical provider and attempt to resolve your claim informally.
  • If you can't resolve it, file an appeal with your health plan. 
  • Keep track of appeal due dates.
  • Need more help?  Call us at 1-877-881-6388.

Filing an appeal.

Appeals are generally made up of the same three phases:

  • Phase 1 ―> Denial of request for service, payment, or coverage
  • Phase 2 ―> Internal appeal to your health plan or carrier
  • Phase 3 ―> External appeal to an independent review organization (if applicable)

When in doubt, ask your health plan to re-evaluate the denial. Your health plan CANNOT drop your coverage or raise your rates because you ask them to reconsider a denial. You’re allowed to ask for an appeal – it’s your right. For more information on the appeals process, call us at 1-877-881-6388.



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