Filling your own Insurance Claim
Situations where the doctor or other healthcare provider (such as us, a vision center, dentist or chiropractor) asks you to pay your bill at the time of care are fairly common, especially when the provider is Out-of-Network or runs a small practice. (Out-of-Network means that the healthcare provider does not contract with, or directly accept, your particular insurance plan.)
Should you still want to be reimbursed by your insurance company (according to your benefit plan), you will need to file a claim on your own. Here is what you will need to do to possibly recover a portion of your costs:
Having the right paperwork with complete information is key! Make sure you have a copy of the receipt from the provider proving you have paid for the medical care. Without this receipt, the insurance company is not likely to reimburse your claim.
The insurance company will need a copy of the itemized bill. (This will be supplied by the provider.) Be sure to keep a copy for your records and make sure the bill includes this information:
- Date(s) of service (the day(s) you went to the doctor or hospital)
- Diagnosis code (sinus infection, strep throat, etc., listed on the bill as a number, such as 461.0)
- Description of services (what they did when you went to the doctor, i.e., blood work, eye exam, etc.)
- Procedure codes for services (these are the numeric codes that represent the services, i.e., 99214)
- Provider name (make sure to include the doctor’s name even if you went to the ER or a clinic)
- Provider address (their physical address or the address for their billing department)
- Provider tax identification number, license number or National Provider Identifier (NPI)
Most carriers require a claim form. On the website of your insurance company, search for a term such as “filing a claim” or “claim form.” If you cannot find a claim form, call your insurance company or your plan administrator and ask them to fax or email you one.
On the claim form, make sure to include your name, member ID number and a daytime telephone number where you can be reached. Make sure you also include a copy of both sides of your insurance card.
Mail the itemized bill, receipt and insurance company’s completed claim form to the address on the reverse side of your insurance member ID card. If you are unable to find this information on your card, call or check the insurance company website.
If there is any information is missing in your claim form, your insurance carrier will likely flag the claim and return it to you to fill out completely and then re-submit.