The Insurance Claims Process

In addition to visit types, there are also medical services that may or may not be covered by your insurance company. And there are health care providers that may or may not be within your insurance company's. These two aspects influence the costs for which you may be responsible. Understanding coverage will help as you navigate the complex world of health insurance.

eligiblearrow-01.jpegTypically, the first thing your insurance company does is make sure that you’re eligible on the date of service reported on the claim. The company will also make sure that the visit type is a covered benefits under your plan and apply benefits accordingly.

 

coveredarrow-01.jpegYour insurance company will then determine if the services you received are covered under your specific policy. If you are covered, please note that it doesn’t always mean they pay 100% of the bill for that service.

The insurance company will confirm that you have received care from a provider that is credentialed in their network. If so, they will determine what the “allowed” amount is, for the visit type, according to their contract with your provider. Typically a discount is applied to the charges.

The insurance company will also determine if a copay should be applied to the charge, based on the visit type. If so, they will consider at least that amount as your responsibility.

They will determine if it is applicable to your deductible. If so, and if you have not paid your full deductible already, they will apply the total allowed amount toward your deductible until the entire deductible amount has been met. If your deductible has been met, they will determine your coinsurance amount and apply that to the total allowed amount.

non-coveredarrow-01.jpeg
Some services are not covered at all by your insurance plan.

It is your responsibility to know what is and what is not covered by your plan as there are millions of different plans that all have different benefits.

If a visit type is not covered by your plan, you will be billed for the entire amount of the billed charges.

Also, if your insurance is not contracted with the provider you see, that is, if they are outside of your insurance company's network, your insurance may not cover the charges at all. It is also your responsibility to reach out to your insurance company to find out which providers are a part of their network.

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