Having medical insurance is an extra layer of protection when something unexpected happens, like an injury or sudden illness. Instead of spending your savings on medical bills, insurance helps cover your hospital expenses.
There’s just one problem: a medical insurance claim is more complex than you think.
It’s easy to presume that if you diligently pay your insurance, you’ll be assured of assistance when the need arises. However, that’s not the case. In worst-case scenarios, your medical insurance claim can even be declined.
When you have medical insurance, there are certain rights and claims that you are entitled to. It’s important to be aware of these so that you can get the most out of your medical insurance coverage. So how do insurance claims work? Keep reading and we’ll tell you what you need to know.
Can You Claim Medical Insurance Upon Admission to the Hospital?
Before we dig deeper into this topic, let us first define what a medical claim is. A medical insurance claim is a payment request that healthcare providers send to your health insurance company. This request for payment covers all the services they rendered during your admission.
Your claim for medical insurance normally begins the moment you check in for an appointment. The entire claims process follows the full journey until you receive medical assistance and finally, the bill.
However, there are many layers involved during the health insurance claims process and you’ll learn them below.
Filing Formal Medical Claims Upon Admittance
Health insurance has what they call provider networks. This is a list of physicians and health providers contracted by an insurance plan to render medical services to members. Doctors within the provider network are called “in-network providers.” Those outside the list are “out-of-network providers.”
What does this entail?
Those in-network providers will be the ones to file the medical insurance claim themselves. After the service, they will gather your claim, plus all necessary details and then forward it for claims processing.
Necessary Procedures For Claiming Insurance
So how exactly do the claims processing work?
Upon receipt of the bill by the insurance claims processing department, they will analyze your claim. Normally insurance covers the costs of medical treatments within their list of benefits and coverage in your chosen policy. If it exceeds your plan, you’ll receive a bill for the remaining costs after insurance coverage which you will shoulder.
Normally, your policy won’t cover medical insurance claims on elective medical services like cosmetics and off-label drugs.
Personally Claiming Insurance Through Medical Bills
When you seek the assistance of out-of-network providers, you will have to file the insurance claims yourself. For this process, you will have to wait until the treatment is over and your medical bills are available.
If you have to do it yourself, here is a quick breakdown of the process:
- Find the correct claims form that corresponds with your benefit plan. Depending on your health insurance company, you may either perform this online or in-person.
- Itemize all your bills and receipts. This is one of the most important details you should have. List down the specific services your doctor provided throughout the process.
- Write all the necessary information including the date of service and medical codes. You may obtain these codes from your doctor’s office.
- There are often time limits allotted to submit claim after receiving medical services. Make sure you accomplish this claim within that period before it’s too late.
- Verify whether the treatment you received is covered by your plan. Otherwise, your claim may be denied.
- Depending on your insurance company, you may need to attach a pre-authorization form before your claim submission.
Legal Assistance on Unjust Medical Insurance Claims
Sadly, not every medical insurance claim gets approved. It’s not the end of the world because there are various reasons why your medical insurance claim is denied. For one, you could have filled out the wrong form. In other cases, you went beyond the time limit or filed without pre-authorization.
Here are some ways you can seek legal assistance for your health insurance claim:
Did Not Receive What Your Insurance Claim Stated
One instance is when you did not receive what is indicated in your insurance claim. For example, you had a medical procedure done but your insurance only covered a part of it. You can file an appeal in this case, and if you need help, consult with an attorney.
Medical Insurance Being Declined
Another instance where you can take legal action is when your medical insurance claim is unjustly denied. This usually happens when your health insurance provider denies your health insurance claim despite its validity.
Once you have exhausted all necessary steps for appeal and still get denied, you may now seek legal assistance. If your insurance company upholds the denial or delays the response to your appeals, you may file a lawsuit immediately.
Medical insurance should be accessible to its members for all their medical needs within the policy. Denying this is denying insured people of the care they deserve. Sandel Law Firm believes that health care is for everyone, and is committed to helping people attain this. Reach out to us for assistance on your medical insurance claim.