Claim (Health insurance claim)

What Is a Health Insurance Claim?

A health insurance claim refers to a request made by either you, or your health provider to cover medical services you received.  These requests come in the form of a detailed invoice, outlining exactly what services were administered.   

How a Health Claim Works

  • The patient is treated by a healthcare professional.
  • The healthcare professional then sends an insurance claim via form or request to a payee.  The payee is usually the health insurance company, or the individual who received the services if they do not have insurance.
  • The insurance company codes according to the diagnosis and treatment. The codes must follow HIPPA regulation.
  • Once the invoice is coded, it is sent to a Universal Clearing House, an establishment for regulated financial exchange, for evaluation.
  • After the claim is evaluated, it is forwarded to the patient with an explanation of benefits. Most often, this statement will remind the patient, “This is not a bill".

How to Submit a Health Insurance Claim

In most cases, submitting a claim is as simple as scheduling an appointment. Your doctor and health insurance company will take it from there.  

Submitting Your Claim

  • If the healthcare provider is part of your network, then they will ask for an insurance card.  This usually means that they will be submitting the claim for you.
  • If you are using an out of network health care provider, or are receiving medical services not covered by your health insurance plan, then you will have to file the claim on your own.
  • Ask your healthcare provider for a detailed, and itemized bill for medical services rendered.  Also, make sure your healthcare provider includes and prescriptions or medication administered or prescribed to you.
  • Attach the original itemized bill to your health insurance company’s claim form, or use a Health Insurance Claim Form 1500.

Health Insurance Claim Form 1500

Form 1500 is a universal healthcare form used by family physicians as well as Medicare and Medicaid. It includes detailed demographic information for the patient and thorough information for the insurance company.

It is maintained by the National Uniform Claim Committee and must adhere to HIPPA regulations.

At times, you may need to see a doctor or specialist outside your network. Double-check your policy and make sure you are aware of additional costs. 

Health Insurance Claims From Providers Outside the Country

If you are an expat, a snowbird or just an avid traveler, you will want to make sure your coverage fits your lifestyle.

  • Study your insurance policy to see if and when you are covered.
  • To file a claim, you need to follow the same process as out-of-network procedure.
  • If you are a snowbird or expat, be sure to check into Global Evacuation and travel insurance. 

To learn more about your health insurance options, give one of our experienced agents a call at 858-771-4087, or enter your zip code into our simple online form!