How To File A Health Insurance Claim

Generally, your health care provider will file the health insurance claim for you with your insurance company upon the rendering of the medical services.

However, there are times where this may not occur. In such a situation,  if you do not want to be stuck with the bill, you should file a health insurance claim.

When May You Need To File A Claim Yourself

Some situations where you may need to file a health insurance claim yourself are:

+ You have paid for the medical services in full: this may occur at a doctor's office, dentist office, pharmacy, or any other medical provider who does not take your insurance.

+ You have a Preferred Provider Organization (PPO) Health Insurance Plan: you may need to file your own claim if you seek medical services from an out-of-network provider or out-of-network hospital or facility.

+ You have a Fee-For-Service (FFS) Health Insurance Plan

+ You have a Short-term Health Insurance Plan

+ You have Medicare and a doctor, hospital, or supplier failed to file a claim with Medicare within 12 months of providing services or supplies.

+ You receive medical care outside the USA.

How Do You Submit A Claim

Submitting a medical claim may slightly vary with each insurance provider, as their process may require certain steps not covered here. But in general, the below steps are what you should follow in order to do submit a claim.

You should check with your health insurance company before submitting a claim to make sure you have all the correct steps according to their process, but if you follow these steps - surely, they will let you know of any others.

1) Obtain Itemized Receipts/Bills

Your health insurance company is going to want to see the receipts for the medical services provided, so you are going to need to ask your medical service provider (doctor, hospital, etc.) for an itemized bill. This will list each service that the medical service provider provided and gives the cost of each service.

Make sure to check the receipt to make sure it reflects the correct services and amount.

2) Obtain Supporting Documents

Obtain any supporting documentation that may be relevant to your health insurance claim. The requirments in the documentation needed (or beneficial to your claim) will likely vary from medical service provider. You can ask your medical provider or insurance company of any supporting documentation that may be recommended/needed for submitting a health insurance claim.

Often times supporting documentation will be something showing "necessity" for the medical service provided, but again this may vary from condition to condition, service provided to service provided.

3) Obtain Health Insurance Claim Form

Obtain the health insurance claim form from your health insurance company - they are often available on their website. The claim form will likely also provide you with additional instructions pertaining to what other information your health insurance company may need from your medical service provider.

4) Review 

Before you send your health insurance claim form in, review your claim form and receipts one last time to make sure you possess and have filled out all the required documentation and that everything is correct.

5) Submit Your Health Insurance Claim Form

Nowadays, submitting your health insurance claim form will likely be capable of being completed online, and if not, by fax. If your health insurance company does not allow such to be submitted online or by fax, you will need to head to the post office.

Contact your health insurance company if you cannot find this information with ease on their website and see if they offer any of the easier options than submitting it by mail.

5) Make Copies / Save All Information On Computer

If you have to mail the claim form, make sure you make copies of everything you are mailing to your insurance company: the claim form, itemized receipts, and any other required information.

If you are lucky enough to be able to submit the claim form online (or even if you mail it), we recommend transferring and saving everything: the claim form, the itemized receipts, etc. under its appropriate folder on your computer for easy access in the future. The insurance company may require more information or reach out to you, so it is nice to have this readily available.

6) Wait For The Decision

Your insurance company may offer an online portal where you can check the status of the specific claim submitted online. 

Your insurance company will also likely give you, upon submission of your claim, a time frame or date upon which your claim will be completed.

Did this help?

Have you ever had to submit your own health insurance claim? Why and what was the result?