Your medical provider usually files health insurance claims on your behalf. You don’t have to deal with the potentially frustrating process of completing and filing your claim — not to mention awaiting approval from your insurer.
But you may encounter situations when you must file your own health insurance claim. In an emergency, you might have no choice but to go to an out-of-network provider that doesn’t work with your insurance company. Or you might get a medical bill you have to pay upfront.
In either case, you have to file a claim yourself if you even want to get partially reimbursed. Fortunately, that’s not as difficult as it sounds. Filing a health insurance claim involves a set of predictable steps. It takes time and effort, but your insurer might be able to help.
How to File a Health Insurance Claim
Follow these steps to file a health insurance claim in any situation in which your insurer can’t or won’t file one for you, such as out-of-network care or an upfront medical bill.
Motley Fool Stock Advisor recommendations have an average return of 618%. For $79 (or just $1.52 per week), join more than 1 million members and don’t miss their upcoming stock picks. 30 day money-back guarantee. Sign Up Now
1. Request an Itemized Bill From Your Provider
First, get an itemized bill from the health care provider that treated you. Also known as a superbill, this document should include:
- All medical services rendered during the visit
- All drugs administered
- Any prescriptions filled at the point of care, such as pain-relieving medication you take home
- All medical supplies or equipment used and billed for
- Any other fees or costs associated with your care
Each expense should appear as a separate line item with a procedure or diagnosis code, unit, value, and dollar amount. The bill should clearly note each item’s place and date of service.
If the provider has a digital patient portal you can log into from your computer or phone, you may be able to pull an itemized bill without contacting the provider directly.
If you can’t find a detailed bill online, look for your bill in the mail. If it includes enough detail to support your claim, you can move on to the next step. If it’s just a basic bill telling you to pay a certain amount, call the phone number on the bill and ask for a more detailed document.
2. Get a Claim Form
Next, get a claim form from your insurance company.
Most insurers post forms you can download on their websites. Visit your insurer’s website and look for a tab or link that says “Forms” or “Claims.” It’s often at the top or bottom of the page.
Contact the insurer’s customer service department if you can’t find the claim form on the website. They should be able to direct you to the form online, email it, or — if all else fails — snail-mail it.
Ensure you’re using the correct form for your insurance plan. Health insurers typically offer multiple plans with different claims processes, and submitting the wrong form could draw out the process.
3. Fill Out the Claim Form
Before you begin, read the claim form in its entirety. Make sure you understand exactly what information you need to provide and how to fill out each section. Determine whether you can fill it out online or whether you’ll need to print and scan or mail it.
Every health insurance claim form is different, but you should expect to provide:
- Insurance Plan Information. This includes your insurance policy number. If you have group health insurance through an employer or trade association, it includes your group ID number. You can find both on your insurance card.
- Patient and Policyholder Information. Patient information includes full name, address, phone number, and date of birth. If you’re the policyholder and you’re filing the claim on behalf of another person, such as a child or spouse, you must provide your own information as well.
- Provider Information. This includes the provider’s identifying information, such as full name, address, and tax ID number. If you don’t know all the information and can’t find it on the website or bill, contact the provider to ask for it. You can also request that the provider fill out this section on your behalf.
- Incident Information. Your form may include a section asking for details about why you sought medical treatment. If so, you must provide the date of the incident, where it occurred, and a brief description of what happened. If the incident involved a car or workplace, other insurance policies could pick up part or all of the expense.
- Other Insurance Information. If you’re covered by another insurance plan, such as Medicare, Medicaid, or a second private health insurance plan, provide the insurer’s name, policy number, and any requested details. If you sought treatment after a car accident, provide your auto insurance policy information.
- Reimbursement Preference. Specify whether you want the insurer to reimburse the provider directly or send you the funds. If you haven’t paid upfront, the insurer will likely reimburse the provider directly.
4. Make Copies
Once you complete your claim form, make at least two copies. Do the same with your superbill and any other supporting documents you plan to submit with the claim. Keep the copies in a safe place, such as a filing cabinet or safe in your home, and prepare the originals to submit.
5. Review & Submit Your Claim
Before submitting your claim, confirm all the information you’ve provided is accurate to the best of your knowledge. Double-check your insurance policy number and group ID, provider information, and any personal information you’ve volunteered.
Next, double-check your superbill for accuracy. Medical billing errors happen all the time, and you don’t want your claim delayed or denied because your provider entered an incorrect code, value, or description.
The best way to confirm your bill has no errors is to call your health insurer and go through it line by line with a claims representative. Though time-consuming, this won’t take as long as waiting for the insurer to process an appeal.
Finally, submit your claim. Many insurers allow you to do so online. Log into your account and look for a Submit a Claim button or something similar. If you submit online, scan any paper documents for upload.
If you can’t submit your claim online, look for the address to send it to on your insurer’s website. It’s often a special P.O. box reserved for mailed claims.
If you can submit your claim form but not supporting documentation online, ensure you know where to send it. If possible, get a claim reference number to clearly mark any documents you mail. Otherwise, your insurer is more likely to misplace key documents and delay approval.
How to File an Appeal for Insurance Denial
Submitting your health insurance claim isn’t the end of the story. Now the ball is in your health insurance company’s court. It has to review the claim and decide whether to approve it.
Insurers often approve the claim and pay their share of the bill — hopefully most or all of it.
But sometimes, they don’t. They either deny the claim outright and refuse to pay any of it or reimburse a much smaller amount than expected. Either way, you’re left with a hefty debt that could weigh on your budget for years to come.
If your insurance company denies your claim, you can appeal the decision. Depending on how far you’re willing to take things, you can involve your state insurance commissioner and civil courts if need be.
As with submitting a claim, appealing one is a multistep process.
1. Review Your Denial Letter
Your health insurance company must send a letter explaining why it denied your claim. This letter should clearly state the reason for the denial and what you can do to change the decision, if anything. Contact your insurer’s claims department if you need help understanding the letter.
Common reasons for denied claims include:
- You received care in another state or country
- You exceeded your plan’s coverage limits
- Your plan doesn’t cover that type of care
- Your insurer decided the care wasn’t medically necessary
- Your claim contained missing or erroneous information, including incorrect billing codes
While you can always pursue an appeal, you should be realistic about your chances of success.
If your claim is clearly beyond your policy’s scope — for instance, it’s for an elective procedure the policy doesn’t cover at all — then your insurer is unlikely to reverse its decision. However, if it denied your claim due to a technicality, such as an erroneous billing code, appealing is likely worth the effort.
2. Find Out How to Appeal
Check your insurer’s website or contact its customer service department to learn how the appeals process works. You may need to fill out a particular form or submit the appeal to a different address. If the insurance company doesn’t offer any written guidance, take copious notes so you don’t miss a step.
3. Keep a Record of All Conversations With Company Representatives
Before and after you file your appeal, make a note of who you spoke with and what you discussed. That will help you put together your appeal letter and follow up on a second denial.
4. Write an Appeal Letter
Next, write an appeal letter addressed to your insurance company’s claims department. Include your claim number, policy number, plan name, dates of service, and provider name.
In your letter, clearly state that you want to appeal the decision. If the company denied your claim for a simple, easily corrected reason, explain that you’re including a revised claim form and spell out what has changed. Ask for reconsideration and sign the letter.
If the company denied your claim for a more complicated reason, such as determining the procedure wasn’t medically necessary, you need to provide more information. That could include:
- A summary of your medical history and why you sought care
- Why you believe the insurer should accept your claim — for example, your provider thought the treatment was medically necessary or you were taken to an out-of-network hospital after a medical emergency
- Supporting statements from the provider who treated you
- Supporting information about the treatment you received if it’s relevant to the decision — for example, academic studies on a particular drug or procedure your insurer doesn’t usually cover
Make copies of these documents and send the originals to the address on file.
Health Insurance Claim FAQs
Having questions about filing your own health insurance claims is common. These answers can help you navigate the process.
How Long Does the Health Insurance Claims Process Take?
It depends on the insurance company and the nature of the claim. Every insurance company has its own claims processing procedures. Some take longer; others are more efficient.
If there are no issues with your claim, expect to hear back within four weeks. If there are any issues with the claim, your lender could take longer to process it before approving or denying it.
How Long Do I Have to File a Claim?
That also depends on the insurance company. Generally, there’s no reason to delay filing your claim. Once you have the bill from the provider, file it as soon as possible. Most insurers stop accepting claims between 90 and 180 days after the date of service.
Can You File More Than One Claim on the Same Form?
No. If you need to submit more than one health insurance claim at the same time, use a separate claim form for each.
You might need to file multiple claims if you received care from more than one provider, even if the reason you sought care was the same.
What Is an Explanation of Benefits?
If your claim is approved, you’ll receive an explanation of benefits (EOB) from your insurer. It’s a detailed explanation of what portion of your care the insurer has agreed to pay for.
You’re responsible for the difference, including your deductible and coinsurance. But you don’t have to send in payment in response to your EOB. It’s the provider’s responsibility to send you a bill if it hasn’t already.
Final Word
If you have Affordable Care Act-compliant health insurance coverage, your plan has a robust provider network and ample consumer protections. But that doesn’t mean you won’t encounter circumstances when you need to seek medical care from an out-of-network provider or pay upfront for treatment.
If you have a less consumer-friendly form of health insurance, such as a short-term health plan, you could encounter these situations fairly often. When you do, it pays to know how to file a health insurance claim and what to do if the health insurance provider denies it.