How to Fill Your Health Insurance Claim Form
- Keeping track of family health history and medical records
- Understanding coordination of benefits
- Increasing your chances of getting your claim processed the first time around
This post stresses the importance of keeping good medical records to make sure that you file accurate claims. This post also explains the standards that determine how insurance plans determine which plan pays first. If you have more than one insurer, knowing the order in which to file your claim can save time and money.
Keeping Good Records
With accurate, up-to-date records, filling out the claim form (a request to pay your medical expenses) should be simple and painless. Correct information on the claim form also lessens the chance that the insurance company rejects your claim or returns it for additional information.
For each person in your family, keep a record — in chronological order — of each event related to a particular condition. The record should include enough information to make reconstructing the details of a condition easy for you. Include summaries and dates of pertinent telephone conversations and correspondence. Keep the form in a file folder and add the appropriate paperwork — copies of bills, receipts, correspondence, prescriptions, and the like — to the file.
Table 7-1 shows an example of such a record. You can change or add to the categories to reflect your own needs. Fill out the record in diary fashion, entering first the date of the next event with the appropriate corresponding information and notes. Add pages as necessary.
Table 7-1: Troy Family Health Record
Claim Information Family Member
Name of patient Helena
Date of birth 10/9/54
Social Security number 111-22-3333
Name of insurance company Happy Health Insurance
Insurance policy group number 0700-131886
Your insurance ID number 123-45-6789
Date of service 1/1/2000
Name of provider, correspondent Dr. Gary
Address and telephone number Dean Medical Center,
for provider, correspondent 1541 Market; 555-4321
Description of services, Saw Helena, prescribed
prescriptions, telephone light diet, bed rest
Notes, comments, questions Requested medication but
the doctor thought we should wait a day or two
Cost of service $65
Amount you paid $15 copay
Amount submitted to the $50
How much the insurance Nothing: Applied the $50
company paid to the deductible
Balance due $50
Date paid balance due 2/5/2000
Claim Information Family Member
Description of services, Saw Dr. Gary again, who
prescriptions, telephone said that Helena didn’t
conversations, correspondence need any medication; she
looked much better
Cost of service $30 for follow-up visit
And so on
You may also want to keep another set of records for each person in your family that covers health history, showing illnesses, injuries, medications, immunizations, and their corresponding dates. For a complete family history, record your parents’ and other relatives’ health information as well.
Ask your provider for a copy of your file — including results of lab work and tests — which you can pick up in person or have sent to you at home. Occasionally, the lab or test results that you get by phone may differ from the written results. Add the information from the file to your family medical file.
In addition to helping you file a complete and accurate claim, keeping good records serves other purposes. If you’re applying for a new health insurance plan, for instance, you may need records as proof of creditable coverage. (Refer to this post How to make sense of variation in health care pricing for more information about creditable coverage.) Save the following:
- Pay stubs showing deductions for health insurance premiums
- Copies of premium payments
- Other evidence of health care coverage
Managing Coordination of Benefits (COB)
Some people have health insurance coverage under more than one group plan. You may have coverage under a spouse’s plan, for example, as well as under your own plan. Group plans use coordination of benefits (COB) to eliminate any chance of duplicating benefits when you submit a claim to both insurance companies. In such cases, the combined benefits that the two plans pay add up to no more than the amount submitted for covered charges.
The insurance industry has established standards for determining the order in which two or more insurers must pay for covered services. The insurer that must pay first is the primary or principal insurer; the second plan is the secondary or lesser insurer. The following rules determine which plan is primary and which plan is secondary:
- If one plan has COB and the other plan doesn’t have COB, the plan without COB is primary (pays first).
- If one plan is for an active employee and the other plan is for a retired person, the plan for the active employee is primary.
- If the patient is the policyholder in one plan and is insured as a dependent under the other plan, the patient’s own plan is primary (unless the patient is a retired person and the holder of the other plan is an active employee).
- If the patient has more than one plan in his or her name, the plan in which the patient has been enrolled the longest is primary.
- If a child is covered by both (not divorced) parents’ group plans, the plan of the parent with the birthday that falls on the earliest date of the year is primary (the birthday rule). If both parents’ birthdays fall on the same day, the plan that began first is primary. The birthday rule doesn’t take into account the actual year the parents were born, just the month.
- Unless a court order states otherwise, if a child of divorced parents is covered by both parents’ group plans, the plan of the custodial parent is primary. (When parents remarry, the plan of the custodial parent is primary; the plan of the custodial stepparent is secondary; and the plan of the noncustodial parent is third in line.)
The standards also regulate the amounts that each insurer must pay. The primary insurer pays as it normally would for covered charges. The primary insurer then submits a statement of the benefits it paid to the secondary insurer before the secondary insurer pays. The secondary insurer picks up the charges for the deductible and coinsurance or copayment. The secondary carrier also pays for benefits covered in the secondary plan but not covered by the primary plan.
If you have more than one health insurance policy, be sure that you understand how the plans will coordinate your benefits. Carefully check each plan to understand how and when to submit insurance claims, as well as which plan to send them to first.
The definition of “coordination of benefits” refers to group plans only. Individual plans don’t usually include a COB clause, although every state has its own regulations governing COB with individual plans. In this case, a person with both a group plan and an individual plan who submits the same medical expenses to both plans may receive duplicate benefits. Although this prospect may sound like a good idea, remember that premiums for individual plans are very high, so you may not come out ahead financially.
Submitting a Claim
To ask the insurance company to pay your providers — or to reimburse you if you have already paid your providers — you submit a claim form. Each health insurance company usually has its own claim forms that it provides to members.
Sometimes insurers accept forms directly from a health care provider’s office as long as the forms include all the information necessary for processing the claim.
If you belong to an HMO or a PPO, you probably don’t need to fill out a claim form for office visits or hospitalization. You simply show your member card. If you’re a member of a PPO and use a provider outside the network or if you have a feefor-service plan, you probably do have to complete a claim form, although sometimes your health care provider fills out the claim form for you.
When you fill out a claim form, a couple of paragraphs in fine print require your signature. One of these paragraphs is the assignment of benefits. When you sign the assignment of benefits, you authorize the insurance company to pay claim benefits directly to the health care provider. If you already paid your provider and want the insurance company to reimburse you, don’t sign the assignment of benefits.
Claim forms indicate what information you need to fill in and which information your provider needs to enter. The patient or policyholder usually fills in the following information:
- Name of policyholder, address, and Social Security number
- Name of the insurance company, group number, and the policyholder’s ID number
- Patient’s name, address, date of birth, sex, and relationship to the policyholder
- Patient’s marital status and work status (employed or student)
- Employer’s name and phone number
- Whether the claim is due to an injury; if so, date of injury and whether the injury occurred at work
- Name, address, and phone number of other insurance company covering patient
- Whether the patient has Medicare coverage
- Signature to authorize release of information and assignment of benefits
When you sign the authorization to release information, you’re giving the insurance company the right to get any and all information relevant to your claim from your health care providers.
Either the patient (or policyholder) or the health care provider may have to fill in the following:
- Date of first sign of illness, or date of accident
- Date of previous instance of same or similar illness
- Dates the patient is unable to work in current occupation
- Name and ID number of referring physician
- Hospitalization dates
The health care provider usually fills in the following:
- Diagnosis or nature of illness or injury
- Dates of service, procedures, and charges
- Federal tax ID number
- Patient account number
- Whether the provider accepts assignment of benefits
- Amount paid and balance due
- Provider signature and date
Double-check that all information you enter on the claim form is legible and correct. Sign and date the form. Make a photocopy for your records and attach copies of itemized bills and/or receipts. (Photocopies are important, especially if the claim is lost and you have to resubmit it.) Bills and receipts must include the patient’s name, date, service, and charge. If the receipt is for a prescription, it must also include the prescription number, the doctor who ordered the prescription, and the pharmacy’s name and address. Mail the claim form and note the date you send it to your insurance company.
Send all your bills to the insurance company, even if you don’t think they’re covered. If you have an expense that you can apply to your deductible, the only way to get credit for that expense is to send the bill to the insurer.
Check your insurance plan carefully for the claim submission deadline — usually 90 days from the date the charges are incurred. If you submit your claim after the deadline, the insurer won’t consider your claim.
After the insurance company receives your claim, it sends you an Explanation of Benefits (EOB) or Explanation of Medicare Benefits (EOMB) to let you know how much it will pay. For each procedure you submit through your claim form, the EOB shows the fee that the insurance company allows. If the company doesn’t pay a benefit on a procedure, the EOB gives the reason for denying benefits. You may appeal a claim if you disagree with the amount paid. See this post for information on appealing a claim.