When you have a health concern, your biggest priority should be to feel better. A doctor can help you with that. And from the moment he or she starts treating you, your health insurance company springs into action to help pay for the services and medications you need.
When it comes to billing, many people don’t know what happens after they check in at a healthcare provider’s office and hand over their insurance card and ID. And that’s understandable. It’s a multi-step process that involves behind-the-scenes communications that can actually be quite complicated. Read on for a simplified version of the payment process for healthcare services, which revolve around something called a claim.
What is a claim?
Most industries have invoices or bills. The healthcare industry has claims. A claim is a request for payment and includes a detailed list of procedures, services, devices and medications received, along with their codes, from a healthcare provider.
Who submits a claim?
Usually, a healthcare provider or pharmacist submits a claim to the insurance company so that they can be paid. But in some cases, you, as a patient, may submit a claim to their insurance company. The latter generally happens if the provider is outside of that patient’s network.
If I’m submitting the claim, as a patient, what should I know?
If you are sending a claim to the insurance company, you’ll want to access the proper forms to fill out. If you’re a Blue Cross Blue Shield of Alabama member, you can get those by calling customer service (the number is listed on the back of your insurance card), or you can find claim forms here for medical expenses, dental expenses, vision or hearing, pharmacy and travel benefits. Be sure and file the claim within two years (24 months) of the service.
What happens when a claim is submitted?
When the insurance company receives a claim, a claims processor will review the paperwork and decide if the items listed are covered by your policy. If it is covered, the insurance company will then pay the allowable amount. The healthcare provider will then bill you for any remaining amount, such as co-insurance, copay or your deductible.
What happens if a claim is denied?
A claim can be denied for a number of reasons. In some cases, the treatment or procedure may not have received prior authorization from the insurance company; or the insurance company may consider the procedure not medically necessary, or a drug may be denied because it’s not covered by your plan. In order to avoid having claims denied, it’s best to check with your health care provider and insurance provider before a service or procedure, so you’re aware of what your plan does and doesn’t cover.
However, if your claim is denied, or your medication isn’t covered, you can request to have the decision reviewed or request an exception. Start by calling the customer service number on the back of your insurance card to learn more about why something has been denied and ask about next steps. You can learn more about the processes here.
What happens after a claim is processed?
As the claim moves along in the system, you’ll receive what’s called an Explanation of Benefits (EOB), which details how your plan is paying for your health care, what it is denying (if anything), what each service costs and any balance you may owe.
Remember, this is not a bill, it’s simply a detailed explanation. However, you may receive a bill from your doctor’s office. If and when you do, be sure and compare your Explanation of Benefits to the bill and make sure they are consistent. If they are, pay the bill promptly. If they don’t match, call your insurance company and doctor’s office to find out why.
To learn more about how to read your Blue Cross Blue Shield of Alabama claims, visit here.