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Health Insurance Guide
Understanding Medical Insurance Claim Forms
You would think that things would be fairly straightforward when it comes to making a claim but unfortunately that’s not always the case. There are many companies selling health insurance plans today and each one has its own set of rules when it comes to making a claim. In fact, even within companies the procedure for making a claim can vary between different types of health insurance plan.
If you are uncertain about what to do when it comes to medical insurance claim forms for a benefit that is covered under your health insurance plan, then your first port of call should be the insurance company itself. The majority of insurance companies have a toll-free telephone number for claims which is staffed during normal office hours. Usually you will need to provide some basic information about your plan, such as the policy number and the name of the principal person insured under the plan. The insurance company representative will then be able to access the details of your plan and advise you on how best to proceed with your claim.
If you have a Managed Care Plan then, as long as you are dealing with something which is clearly covered by the plan, you should find that the process is very easy. In most cases, the staff at the front desk of the medical facility where you have your treatment will deal with the paperwork for you. They will input the medical codes for your treatment and the services provided and send the paperwork directly to the insurance company on your behalf. If a co-payment is required you will normally be asked to pay this at the time that treatment is received and you do not need to take any further action until you get the paperwork back from the insurance company. This paperwork will show the amount paid by the insurance company, the sum applied towards the deductible and whether there is any balance due from you.
Until very recently indemnity health insurance plan holders were required to pay in full for any treatment provided at the time of treatment. There were then lengthy claims forms to be completed and submitted to the health insurance company for reimbursement. Thereafter, it would typically take several weeks before reimbursement was made.
Today however it is increasingly common for the medical facility at which treatment is carried out to bill the health insurance company directly and then wait to see what percentage the insurance company pays. If there is any balance to be paid the medical facility will then bill the patient.
If there is a dispute the medical services provider will normally bill the patient directly and, in such cases, the patient will have to pay. It is then the patient’s responsibility to seek reimbursement from the health insurance company.
Modern computerized medical billing means that patients today do not usually have any out-of-pocket expenses, other than any co-payment. If there is a need for patients to first meet their deductible the paperwork is still normally sent to the insurance company so that an accurate record can be maintained of the policy’s usage and its payment history.
As a result of the enormous sums of money involved in health care today claims are usually settled very quickly.
Credibility: A measure of the statistical predictability of a group's experience.
Drive time: A measure of geographic accessibility determined by how long members in the plan's service area have to drive to reach a primary care provider.
Peer review: The analysis of a clinician's care by a group of that clinician's professional colleagues. The provider's care is generally compared to applicable standards of care, and the group's analysis is used as a learning tool for the members of the group.
Standard community rating: A type of community rating in which an MCO considers only community-wide data and establishes the same financial performance goals for all risk classes. Also known as pure community rating.
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