Review your policy or employee booklet carefully to make sure the plan covers the service in question. If you have any reason to think a health care service may not be covered, or that your company disagrees with your understanding of the policy, talk it over first with your provider and with the insurance company. Resolving questions first can prevent problems later.
You should never assume your plan will cover a treatment or service. Follow your plan’s rules, including pre-certification requirements and use of network providers. Your provider may require you to make a copayment or pay your coinsurance at the time of visit.
Fill out any claim forms the provider or insurance company gives you. Be sure to include your policy number and other identifying information.
How to submit a claim yourself:
- Find out if your provider submits the claim for you or if you need to do it.
- If you need to do it, review the claim information to make sure it is complete and correct.
- File the claim as soon as you get the bill from the provider.
- Send it to the correct address.
- Keep a copy for your reference.
- Wait for your company’s statement before you pay your provider directly.
- Allow reasonable time for the company to process your claim. The company must inform you if it needs any additional information to complete the claim. Sometimes, it will request additional information directly from the providers; in other cases, it will return the claim form to you to get more information.
- They should state the reason on your explanation of benefits.
- If you disagree with the reason for denial, check your policy or employee booklet for the company’s appeal procedures.
- The company should answer procedural questions about appeals over the phone. Call the company’s assistance line (the phone number should be listed on your statement).
- Submit your appeal in writing. The company may require information from your doctor.
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