Having a hard time getting that health insurance claim paid or have questions about what's a payable benefit? Maybe this should help.
Like many people I didn't have a regular physician and whenever I had a minor ailment I found myself in one of those quick clinics. While nothing was ever life threatening before I made an appointment I'd call to first find out if they participated with my insurance carrier. Before making any appointment you should contact the physician's office and ask if they participate with your carrier.
If they participate with your carrier go ahead and make the appointment, but remember you may have a co-payment (if the doctor is a participating member in a Preferred Provider Organization- PPO) for an office visit or you may have to pay directly for an office visit since most are non payable benefits. You may have to pay for an injection if needed.
However, if your physician determines you need further tests to help diagnose an ailment ask the receptionist at your physician's office to give you a procedure code of the test. A procedure code is five digit number which defines the service. You can call your insurance provider with this number and they can assist you as to if the procedure is payable under the terms of your policy. Most customer service representatives will ask for this number.
For certain procedures you may need to have a diagnosis code which relates to the test you may be facing. Both a procedure and diagnosis code are usually used for CT Scans.
It's also a common practice for doctors to submit laboratory or radiological tests to a local hospital for review so don't panic when you receive an Explanation of Benefits (EOB) form with the name of a hospital on it. Automatically your mind will tell you this may be a case of fraud since you weren't at the hospital and generally after calling the insurance company they'll ask if you were seen at the doctor's office on the day in question.
When a doctor or hospital bills the insurance company they will usually do it electronically and in many cases claims will reject due to lack of information which was submitted at the time the claim was billed. If this happens contact your carrier and ask what information is required. Chances are your medical records will be needed for further review.
Depending on your insurance carrier they will request them for you or they may refer you back to the provider to obtain them yourself. Once the records are obtained they will be manually reviewed for payment consideration.
You should also know that many doctors and hospitals are required to submit claims two years from the date of service. Claims which are submitted after the filing date are ineligible for payment consideration and you should not be held liable for their error.
Unfortunately, billing clerks in both venues "think they know it all" and they "have the power." Do not let them intimidate you. So if you do encounter a problem contact your carrier and explain the situation to them. They may be able to help resolve any outstanding issues when it comes to paying a claim.
The same holds true if you find yourself dealing with a collection agent. These vultures are lurking in the wings since most hospitals are expecting payment the moment you check out of the hospital. (If you are hospitalized it's best not to have a television or a phone in your room since they charge a large fee and these charges are always hard to figure out. While you are responsible for the payment of them they may try to keep collecting the money after you've already paid them).
When you first receive a notice from a collection agency call your carrier immediately for a status of your claim. Again they should be able to assist you regarding this matter. If they haven't received a claim for the date of service contact the billing department of the doctor or hospital and always be sure to document the day, time and who you spoke to.
Sometimes claims do fall through the cracks but hopefully this information should be helpful when it comes time to having a claim paid.
By: Eric Tuchelske
