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How do health insurance claims work?

How do health insurance claims work

How do health insurance claims work?

A health insurance claims is all about requesting an insurance company for reimbursing the money that an insured individual has spent on medical services and hospitalization bills. Health insurance benefits or payments are obtained after one submits the claim to the insurer. However, before you go ahead and file one, you need to know about the filing procedure and the information needed to file it.

How does the claim process work?

The first step involves you or your physician filing a claim with you’re the insurance provider. If the physician, hospital, or clinic is within the PPO network, the doctor can file a claim on your behalf. But, if the doctor is outside the PPO network, you may need to file a claim by yourself.

To file your own paperwork, you can start by logging into the Client portal to complete the Claims details or by completing the Claims form and submitting it to the insurance company.  Key pieces of information that you have to give are:

  • Your insurance policy number, group plan number, or member number
  • Who the Claim is for including the name and other personal details.
  • The reason for visiting a doctor or hospital including complete details on what happened
  • Name of the doctor/ hospital/medical facility you got treated at

The biggest benefit of using online portals for health insurance claims is the fast processing of the payments. Once the documents are submitted, the insurance company  will check what portion of the claim is covered, your deductibles, co-insurance clauses, and process the payment.

Cashless claim process

For a cashless claim, the policyholder needs to be treated by an in network provider.  To get cashless treatment in a hospital, the insured individual needs to present his/her ID-card and provide the contact information of the insurance company which is available on the ID Card. The hospital can bill the insurance company for the treatment received by the policy holder.  The insurance company will  evaluate the bills and process the claim per the terms of the policy.

 Claims could be for a planned new surgery or an unplanned treatment/emergency.

  • Claims for planned  new surgery– In this case, the insured individual needs to verify benefits and eligibility with the insurance company  about the treatment or hospitalization  before the treatment date. The  After all the steps are completed, the insurer will notify the hospital about the eligibility and policy cover. On the admission day, the policyholder needs to show his/her insurance card and confirmation letter. The insurance provider will directly pay the medical bills to the hospital.
  • Claims for unplanned treatment– Unplanned medical treatment generally happens during an emergency. The policyholder can contact the insurer and get the information of the nearest hospital within the network. The insured individual can show his/her insurance card, and ask the provider to get in touch with the insurance company for pre-certification if needed.  The insurance company will receive all the bills from the hospital. In case the claim is rejected, the insured individual will receive a letter, citing the reasons for rejection.

Reimbursement claim process

If the insured does see a provider who is out of network or for some reason the provider cannot bill the insurance company directly or gets prescription drugs,  payment might have to be made upfront and then claims submitted for reimbursement. In this case, he/she can’t use the cashless treatment facility, hence he/she has to pay their medical  charges and then claim reimbursement.

To get the reimbursement claim, you need to provide the insurer with the necessary documents. The insurance provider will evaluate the claim, check the policy coverage, and then processes the payment. If the treatment doesn’t fall under coverage, your claim can be rejected.

Documents needed are:

  • Duly filled claim form
  • Bills and receipts of the medical treatment received
  • A medical certificate signed by your doctor
  • Discharge certificate from the hospital
  • Prescription from pharmacies
  • Investigation report/doctor notes and documents which typically are sent directly to the insurance company on request.

How does claim processing work?

How do health insurance claims work

After your treatment, either you submit a claim for the medical services you received, or your physician sends a bill to the insurance company. A claim processor will check the claim’s accuracy, work on network discounts if any, and check for the eligible benefits on the plan along with the deductibles and co-insurance. . Remember that the insurance company will only pay only for the benefits per the policy terms for an eligible illness/injury.

If the policy is a Limited benefit plan, it will have pre-defined  sub-limits on the benefits. After the Claims are reviewed,  the  pre-defined sub limit  will be paid by the insurance company after the deductible has been met. Anything above the pre-defined amount  to the actual billed amount needs to be paid by the insured individual. Sometimes, the entire cost could be covered, while sometimes only a portion depending  on the health benefits that he/she has opted for. Copay, coinsurance,  deductible, and other information will also be checked before settling the claims.

What happens after the claim is processed?

The policyholder will receive an Explanation of Benefits (EOB), showing all the details of the services covered and paid for. The hospital or clinic will also send you a bill for the medical services received. The next step involves comparing the EOB with the final hospital bill and paying the doctor. The policyholder needs to pay the amount that they owe.

The insurance claim process may seem complicated, but don’t worry, you got us by your side! With Visitor Guard®, you can have a smooth claim process and get reimbursed without much hassle.


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