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How do I make a health insurance claim?

Keep in mind...
  • Medicare and Medicaid are the two health-insurance programs funded and administered by the federal government
  • HMO and PPO insurance plans are not the same
  • Out-of-network services usually result in out-of-pocket expenses

According to the most recent statistics from the Centers for Disease Control, nearly 65 percent of all American adults under the age of 64 have private healthcare insurance coverage.

For those who are part of this group, filing a health insurance claim is a process that depends mainly on the type of health insurance plan you have.

Some plans require participants to file claims for every instance where service is used, while others require nothing at all from patients.

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How do health care billings differ?

adobestock_83197332-1600x1600To understand how filing health insurance claims applies to each of the following plans, it’s important to first know the difference between direct billing and third-party billing.

In a direct billing scenario, your medical provider supplies your care and then sends the bill directly to your health insurance company.

You may pay a small co-pay fee, but other than that, you will have no knowledge of how much the medical procedure costs.

In a third-party system, the subscriber pays the bill himself and then submits a claim to the insurance company for reimbursement.

Most health insurance plans use one system or the other. A small handful combines the two depending on the type of care you require.

The third type of model, which isn’t health insurance at all, involves a healthcare cooperative where a group of individuals gets together and agrees to share the expense of everyone’s medical bills.

How are claims filed with an HMO?

Health maintenance organization (HMO) is by far the most common type of healthcare plan used in the United States.

According to the strictest definition of the term, the HMO is not even true insurance.

It is a direct billing system, which usually requires co-payments based on the type of procedure being sought. To file a claim with your HMO you simply:

  • Visit your healthcare provider
  • Present them with your insurance card
  • Pay your co-pay
  • You’re on your way
  • They will bill your plan directly

There may be exceptions to this system for things like major hospitalization for catastrophic care.

Such high-ticket items might require you to fill out some extra paperwork to send it to your insurance company.

If so, the paperwork will be provided by either the insurance company or the medical facility providing the care.

Most often, this type claim needs to be filed if you have exceeded your annual limits and need further assistance because of a catastrophic event.

How are claims filed with a PPO/PPN?

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PPO (preferred provider organization) and PPN (preferred provider network) plans are virtually identical.

Under a PPO health insurance or PPN healthcare plan, doctors and medical facilities agree to become part of a healthcare network, which guarantees them so many patients annually.

In exchange, they offer the program slightly reduced rates. Subscribers only need to pay a small co-pay as long as they utilize physicians who are part of the network.

If care is required outside of the network, how you file a claim will depend on the facility’s billing system.

Because that facility is not part of the network you will, in all likelihood, have to pay for your service out-of-pocket and then submit the bill to your insurance plan for reimbursement.

For purposes of streamlining the system, your plan may accept direct billing from major hospitals and certain prestigious medical facilities as a way to avoid third-party billing.

How are claims filed with a POS?

Filing claims with a point of service (POS) plan is very similar to doing so with a PPO/PPN. A POS plan ostensibly combines the best aspects of an HMO and a PPO to achieve better care at lower prices.

All subscribers to a POS plan must choose a primary care physician who becomes the main decision-maker in guiding the patient’s healthcare.

As long as the subscriber receives care from their physician, or another doctor he refers the patient to, all the bills and paperwork will be taken care of by the healthcare providers.

On the other hand, if a subscriber seeks care outside of his primary care physician’s office or referrals, he will have to pay the bill on his own and then submit it to the insurance company for reimbursement.

In many cases, reimbursement will only be a partial payment. This is done in order to discourage subscribers from seeking care outside of the parameters of the plan.

How are claims filed with Medicare/Medicaid?

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Medicare and Medicaid are the two health-insurance programs funded and administered by the federal government.

Medicare is designed for individuals age 65 and over, regardless of their income level, while Medicaid is for non-seniors who qualify as very low income.

Both programs work similarly regarding receiving care and filing claims.

Both utilize the direct billing system that keeps the subscriber out of the loop regarding knowing how much a particular medical procedure costs.

Medicare and Medicaid subscribers are given an ID card, which they present to a healthcare facility when seeking treatment.

That facility takes the appropriate information and bills the insurance plan directly. If co-pays are required, those must be rendered at the time service is received.

It must be noted that not every facility or doctor’s office accepts Medicare and Medicaid. Their reimbursement levels are substantially lower than private insurance, thereby causing some doctors and facilities to refuse to accept patients on those plans.

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