MEDICAL INSURANCE CLAIMS PROCESS

MEDICAL INSURANCE CLAIMS PROCESS

A health insurance claim is a bill for health care services that your health care provider turns in to the insurance company for payment.
Your insurance claim actually begins before you even make an appointment. Your insurance carrier is responsible only for paying for benefits that are covered under your policy. It is important to read your policy thoroughly so you know what is covered and what is not covered before receiving medical attention.
The health provider will then ask for your medical card or any identification document from your insurance for verification. They will then present you with a claim form depending on which insurance carrier you had bought your cover from.
After filling all the required details on the form, you will return the duly filled form with your medical card or that of the patient to the health provider. At this point, you are free to receive medical attention.
After you have received medical attention, your health provider will attach your claim form to the bill/invoice and send it to your insurance carrier claims processing department for settlement. The claims department personnel then go through the documents to ascertain whether all relevant information from the doctor and the patient are provided. These are compared to the insurer's explanation of benefits to see if the policy covers the services offered. If it does, your insurance carrier will submit payment for the service within the period in the contract.
Some claims are rejected and returned to the health provider for various reasons listed below;
Common Reasons for Denied Claims
• Treatment sought without prior authorization
• Improper claim filing (missing information, illegibility)
• Claims not filed within time limits
• Treatment not covered by policy
• ¬Procedure deemed medically unnecessary

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