By Health Insurance Claims
Health insurance is an important part of our nation’s healthcare system, protecting us from the high costs associated with illness and injury. It does this by paying out for services or medical devices you use to treat yourself or someone else, such as prescription medications.
When a patient uses their insurance to pay for a doctor’s office visit, hospitalization or any other medical service, they submit a claim to their health insurer. The process is similar to submitting a bill to your credit card company, except that a claim is an itemized list of the medical services provided.
The process is complicated and it often takes a while to get your claims paid. This is because your health insurance company has to go through a series of checkpoints before they approve any claims.
How Health Insurance Claims Work
After Gabe’s appointment, the doctor’s office sends his claim form to a third-party administrator or claims processing department. It is sent through an automated system to ensure the information is accurate and complete. Then it’s sent to Oscar, the company that manages Gabe’s health insurance.
Understanding Health Insurance
Once Oscar gets the claims, it reviews them to make sure they contain no errors or duplicate charges. It also checks that the doctor filed them within Oscar’s deadline.
It’s not uncommon for claims to be rejected by health insurance companies because of errors or incomplete information, but this happens less frequently these days. The insurance company’s process for approving or rejecting a claim has evolved over the years, and these processes are becoming more automated.
There are 20+ checkpoints that all insurance claims must pass through before being approved or rejected by the insurance company. These checkpoints are designed to catch any issues or mistakes before they become serious and result in denials, payment delays or other negative outcomes.
Explanation of Health Insurance
If your insurance company refuses to pay a claim, you can appeal the decision in writing and ask for an external review by an organization outside of your insurance company. This external review organization will then determine if the insurance company’s internal review was correct and if they should have to pay for the service, medication, or device you need.
You must file the external appeal in writing within four months of receiving the insurance company’s internal review. This means that the time you have to appeal your insurance company’s denial is limited, so it’s important to take action quickly if you need a service or device and think your insurance company is wrong.
Your insurance provider will likely provide you with a set of forms to fill out when you visit the doctor or when you are bringing in your medications. These forms have a list of the services you need and the medical codes that are necessary to process your claim.
The forms will ask you to describe the medical service and include any other related information you think is relevant. You’ll also have to include any relevant prescriptions that you’ve received in the past.