Whether you visited your doctor’s office for routine care or ended up within the emergency room with a broken wrist, you’ve probably received a medical bill. But do you understand what happens before the bill makes its option to you?
No? You’re not alone. The medical claims process is a mystery to many, and reading a medical claim or the bill that comes out of your doctor’s office isn’t all the time straightforward. But don’t worry, we’ll walk you thru every little thing you must know – from the varieties of claims to how they’re filed and every little thing in between.
What is a medical claim?
A medical claim is an invoice (or bill) that’s submitted by your doctor’s office to your medical insurance company after you receive care. Each claim has an inventory of unique codes that describe the care you received and help your health plan process and pay them faster.
HealthPartners members can view processed medical claims of their online account anytime.
The common varieties of claims
There are several types of claims, depending on the care you get and the plans or products you have got, including:
Medical claims
A bill that your doctor sends to your health insurer on your medical care. These could be from a health care provider’s office, urgent care, hospital, emergency room or every other provider who cares on your body.
Dental claims
A bill that your dentist, orthodontist or oral surgeon’s office sends to your medical insurance on your dental care.
Pharmacy claims
A bill that your pharmacy sends to your medical insurance company for medications that you have got gotten. This could be for normal prescriptions or for medications you needed while receiving other care, corresponding to within the hospital. In that case, you’ll have each medical and pharmacy claims for a similar care visit.
Consumer-directed health plan (CDHP) claims
Claims that you simply submit for health care expenses you’ve got paid for that could be reimbursed by a pre-tax account, corresponding to a versatile spending account (FSA) or health reimbursement account (HRA). These might include bills that you’ve got received for care or prescriptions, in addition to other approved expenses like eyeglasses or over-the-counter medications. These are submitted by you on to the corporate that administers your FSA or HRA.
How a medical claim is created
When you received care in your plan’s network, your doctor’s office will submit a claim in your behalf. This happens robotically and you generally don’t should be involved in the method.
But for those who received services outside the network, chances are you’ll must file a claim yourself. When you’re a HealthPartners member, one of the best option to do that is to submit a claim online.
How long you have got to file a medical claim for out-of-network services
To be certain your medical bills are processed quickly and paid on time, the earlier you file your medical claim, the higher. Many medical insurance corporations offer you as much as 90 days after the date you received care.
How health care claims processing works
Let’s follow the life cycle of a medical claim from the moment you check in on the doctor’s office until you receive a bill:
- You fill out an intake form at your appointment together with your personal information and insurance details.
- The doctor’s office verifies your insurance information.
- You receive care. Your doctor or care team makes notes in your medical record in regards to the care you received, what you talked about, and any medications that you simply were prescribed at that visit.
- Your doctor’s notes are copied into standardized medical codes to explain the care you received and why.
- A medical billing specialist on the doctor’s office enters the costs that the clinic charges for every medical code onto a medical insurance claim form. This is usually an automatic process and tells your insurance company the price of the care you received.
- Your claim is transferred out of your doctor’s office to your medical insurance company. This is usually done electronically.
Your doctor’s office decides how often they send claims. Many send them every day, but some send them weekly and even monthly. They can also send the claims for certain varieties of care in batches – corresponding to for those who got multiple physical therapy appointments, the claims may be sent in a batch of three or 4 visits at a time. How your doctor’s office sends claims will affect how quickly and in what order your health plan pays them.
- Your health insurer makes sure the knowledge sent by your doctor’s office matches standard medical codes, then compares it to your health plan advantages and figures out what’s paid by your plan and what you’ll owe. If there are any coding discrepancies, your health insurer may send questions back to your doctor’s office to make clear what care you received.
It is important that the codes are correct, as they can change what profit your care is roofed under. For instance, if the medical code indicates that you simply had a screening mammogram, that’s generally covered by your plan’s preventive services profit. But when the code is for a diagnostic mammogram, that indicates you had symptoms that required the mammogram to diagnose an issue. That may likely be covered by your plan’s diagnostic imaging profit. Those advantages have different coverage, so what your plan pays and what you’ll owe would differ.
- Your health plan completes processing the claim. It sends a payment to your doctor’s office for the price covered by your plan and tells them what you continue to owe to cover the total cost.
- You’ll often receive a proof of advantages (EOB) out of your health insurer in regards to the claim, explaining how it was paid and what you owe. And you may receive a bill out of your doctor’s office for any costs not covered by your plan. You pay that on to your doctor’s office.
How long health insurers should pay claims
Your health plan must let you understand in case your claim is being accepted or denied inside 30 business days of receiving a claim. HealthPartners pays most submitted claims inside 4 weeks.
But processing a claim can take longer if all of the vital information wasn’t included in the unique claim submission, if medical codes don’t match or if other errors were made.
How you can read a medical claim and EOB
The formatting of your medical claim and EOB will vary by insurance company, nevertheless it normally includes common medical insurance terms like:
- Total cost of service: That is the entire cost of the care that you simply received. When you didn’t have insurance, that is the quantity you can be billed.
- Member savings: That is the discount you’re getting on the entire cost of the service by being a member of your health plan. Medical health insurance plans like HealthPartners represent a whole bunch of hundreds of members, so they can negotiate cheaper prices in your behalf.
- Plan paid: That is the quantity that your health plan paid on your care. This can vary by the variety of service, in addition to where you’re at in your deductible or out-of-pocket maximum.
- My responsibility: That is the quantity you owe. Your doctor, clinic or hospital will send you a bill for this amount.
The importance of a medical claim number
Each medical claim has a singular claim number assigned to it to make it easy to discover. So, once you reference that number to someone on the clinic or member services at your insurance company, they’ll have the opportunity to know what visit you’re talking about and be more prepared to reply your questions.
When you’re a HealthPartners member, you could find your claim number within the top-right corner of your EOB.
What if my claim is denied?
You will likely be notified in your Explanation of Advantages in case your claim is denied, and why.
A claim could possibly be denied for quite a lot of reasons, including that your plan doesn’t cover among the care you received, or it was from a clinic or doctor that won’t covered. It can also occur in case your health plan hasn’t received additional information they must process the claim, like Coordination of Advantages details.
In case your claim is denied, you’ll have the appropriate to ask that or not it’s re-reviewed by filing an appeal.
Submitting a medical claim to HealthPartners
If you have got an issue about how to file an out-of-network claim with us, we’re here to assist.
When you’re a HealthPartners member, you may sign into your online account to view your claims and EOBs or call Member Services on the number on the back of your member ID card.