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What is a healthcare claim form?

Keep in mind...
  • A healthcare claim is a bill that you or your healthcare provider turn into your insurance company in order to receive payment
  • CMS 1500 is a common healthcare claim form, though you should always check your insurance provider’s site to see if they have their own claim forms
  • You will need to obtain policy and group numbers, healthcare provider ID numbers, receipts for services, and a reason for treatment in order to fill out a healthcare claim form
  • Filling out a health care claim form may require an understanding of what EOB, HICN, NPI, CLIA, co-pay, coverage, and deductible mean
  • Following certain tips and guidelines can help you to be certain that you will receive the payment of benefits you’re seeking

What is a health care claim?

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Because there are plenty of complicated parts to a healthcare claim, it’s best to start with a very simple definition. How Stuff Works gives the definition of a healthcare claim as “a bill for health care services that your health care provider turns into the insurance company for payment.”

The bill presented is an itemized list of treatments, medications, tests, fees and other expenses incurred during treatment.

The itemized list, known as an explanation of benefits (EOB) will be evaluated by the claims agents of your insurance company in order to find those items which are covered by your policy; there will also be a list of exclusions.

Once the claim EOB is evaluated, the insurance company will pay the proper amount of the benefit for your claim and the rest will be billed to you.

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What form do you need in order to make a health care claim?

Though most healthcare claim forms are filled out by your health care provider, that isn’t always the case. If your health care provider is not in your health insurance carrier’s network, then you might have to fill out the health care claim form yourself.

In either case, is helpful for you to know which form you might need in order to file a health care claim. The generally accepted form for a health care claim is the CMS 1500 form.

Important note: You should call your insurance company and/or check their site to figure out what form they accept and if they have their own health insurance claim forms for policyholders to submit.

Whether you file online or mail inyour claim, oyou will need to know what information is necessary for the claim to be accepted and for you to get the most out of your health care benefits.

What information do you need to fill out a health care claim form?

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For a claim form to have any chance of being accepted, the most important item or items you will need are itemized bills, invoices or receipts. “An itemized bill lists every service that your doctor provided and gives the cost of each of the services,” says Mila Araujo in an article for the Balance.

Tip: If you are sending your claim through the mail or delivering it directly to your health insurance carrier, make certain that you keep copies of your receipts for your own records.

An itemized receipt should include all costs for each individual, medication, test, treatment or consultation that is being claimed on the EOB portion of the health care claim form. In addition to itemized receipts, you need to have the following information ready as well:

  • Policy number, group number and/or member number
  • Specific person who received the medical service for which you are making the claim
  • If there is coinsurance or dual coverage to be considered
  • The reason for the visit, treatment or hospital stay

Make certain that all of the information you provide is clear and accurate before you start filling out your claim in order to avoid potential errors that will delay your claim from being processed.

What are some of the terms that will be used to fill out a health care claim form?

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Health care claim forms are littered with acronyms and abbreviations, so it is helpful to know the definitions of those acronyms and what you will need to provide to meet the requirements of your health insurance claim.

EOB: Explanation of Benefits are the itemized list of medications, treatments, tests, and fees for which you are making a claim.

HICN: The Health Insurance Claim Number is the number used to reference your claim; make sure that you fill out all of the digits accurately whenever it is asked for.

NPI: The National Provider Identifier is a number used to identify health care providers. If you don’t know it, you can look it up on the NPI Registry.

CLIA: This acronym stands for Clinical Laboratory Improvement Amendments, which is the governing body that certifies and regulates clinical laboratories.

Besides understanding these popular acronyms, you’ll need to understand terms like:

  • A copay is a fixed payment for medical service that is paid at the time of service.
  • Coverage or coverages are items that are included in the benefits of your insurance policy.
  • A deductible is the amount of money you will have to pay before the insurance company takes over paying their portion of your insurance benefits.

Make sure that you get an accurate definition of any term that you do not understand before submitting your claim.

How do you fill out a health care claim form?

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Once you have gathered and made copies of your itemized receipts, have identified and recorded the different items necessary for filling out the proper form, you can begin to work your way through the actual form with greater accuracy. There are two ways to submit claims; electronically and paper.

Electronic forms will typically guide you through the process in an organized and easy to understand manner, so we will focus on filling out a paper form.

All Things Medical Billing provides a list of tips that will help the submission of a paper application have a much higher likelihood of being processed correctly and more rapidly. Here are a few of those tips:

  • Use a 10-point, plain font when filling in forms.
  • Use uppercase capital letters.
  • Do not use dollar signs, decimals or punctuation.
  • Make sure you use individual provider names and not facility names.
  • Make certain that all identification numbers are accurate and in the accepted format without dashes or hyphens.
  • Do not staple, clip or tape documents to the form.
  • Make sure the forms and documents are clean, free of stains, handwritten notations, cross-outs, strike-overs or white-outs.
  • Submit in a full, letter-sized envelope in order to avoid excessive creases or tears. These documents are likely to be scanned and they will scan easier without these added difficulties.

Besides following these tips, it is good to have a set of instructions for filling out the CMS 1500 health care claim form beside you in order to help clarify what information is being requested by the form and the proper format for providing that information.

Bonus Tip: It’s a good idea to create a checklist of all of the forms, receipts, proof of payment documents, and other information that will be included with the form submission. If you prepare this checklist and then work through the checklist as you include the items in the envelope, you will be less likely to leave out essential documents from your claim form package.

What if there are issues with your health care claim or it is denied?

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In spite of your diligence in following the tips we provided above, your proper understanding of the terms and double-checking your accuracy, there could be further issues is getting coverage for your health care claim. In those cases, coverage will either be delayed or declined while particular issues are sorted out. If your initial attempt fails, don’t panic, your claim might still be covered, but you might have to take some additional steps.

Steve Brozak, writing for Forbes, lists The 5 Things You Should Know When Your Healthcare Claim is Denied. By following Steve’s advice and even understanding common pitfalls beforehand, you have a much better chance of making certain that your health care claim form will yield the benefits you are hoping for.

Knowing the proper form to use, the necessary terms that you’ll be using, having the essential supporting information and following certain tips when filling out your health care claim form, you can make an overwhelming task much easier to bear.

If you have any further comments, tips, suggestions or questions about health care claim forms, please include them below.

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