Understanding the Health Insurance Claim Process

hi I'm al red Murr of the Maryland insurance administration understanding your rights when an insurance company does not pay all or a portion of your bill for medical services is critical to making sure that you receive what you are entitled to under your health care plan this short video will explain some of the basics of the claims process as an example let's assume that you have knee pain and go to your primary care physician you have a 1000 dollar

deductible and have already applied seven hundred and fifty dollars to it you also have an x-ray and a follow-up visit with your doctor all of the providers you visited are in-network after you receive medical services or get a prescription filled your medical provider your pharmacy or you will file a claim with your insurance company for payment for the service or medication in our example since all of the providers

are in network they file the claims for you the insurance company processes them in the order in which they were received the insurance company will review the service and determine if it's covered by your contract if it is covered by the contract the insurance company will pay in accordance with your contract - any of the following that you are responsible for under that contract for example number one your deductible this is the amount of money you must pay

towards coverage services before your insurance company will begin making payments the deductible may not apply to all services that are covered by your policy or plan contact your insurance company for a list of services that are not subject to a deductible under your policy or plan for a service subject to the deductible you or your health care provider will submit a claim to the insurance company even though you are responsible for paying the provider the

insurance company will then apply the allowable mound for covered services to your deductible when the total of allowable amounts equal your deductible the insurance company will begin to pay claims until you meet your deductible you will need to pay the allowable amount to your health care provider after you meet the deductible you will pay only the applicable coinsurance or co-payments ette dollar amount that you must pay for a particular service the amount may be

different based on the type of service and whether the service is provided by an in-network or out-of-network provider for example your plan may require a twenty dollar copay for an office visit to an in-network provider but in a forty dollar copay for an office visit for an out-of-network provider this fee may be in addition to any deductible for which you are responsible under the plan so

let's return to our example your primary care doctor submits a claim to the insurance company for three hundred and fifty dollars for the first visit the health plan has an allowable amount of 250 and the insurance company applies that to your deductible you are responsible for a two hundred and fifty dollar payment to your doctor plus the twenty dollar copay since your doctor is in network she accepts the two hundred and fifty dollars plus your

twenty dollar co-payment as payment in full for your follow-up visit if you have met your deductible you will only be responsible for the twenty dollar copay and number three is coinsurance this is the share of the cost of a covered healthcare service the coinsurance is applied after any deductible has already been satisfied your share is a percentage such as 20% of the allowable amount for the service

now here's how it works first let's say your x-ray costs $200 then the insurance company has an allowable amount of 150 dollars if your coinsurance is 20% assuming your deductible has already been satisfied you pay 20% of the 150 dollars which is 30 dollars and the insurance company pays the remaining 120 dollars the insurance company could also determine

that it will only pay for a portion of the claim or it may determine that it will not pay any of the claim at all now if the insurance company decides not to pay for some or all of the services it must send you an explanation of benefits otherwise known as an EOB the EOB provides details about a health insurance claim such as what portion was paid to the health care provider and what portion of the payment if any is

your responsibility as important to note the EOB is not a bill if the insurance company's decision is based on lack of coverage under your health plan that's called an a coverage decision if it's based on a lack of medical necessity in other words they don't think the medical procedure is necessary that's called an adverse decision if you want to ask your health insurer to reconsider its coverage or adverse

decision follow the instructions in the first gob or in your insurance contract to file an appeal for a coverage decision or a grievance which is for an adverse decision you may wish to ask your treating healthcare provider to help you with the process or to actually do it on your behalf once you file an appeal or grievance with your health insurer the original decision will be reviewed by the health

insurer if it was an adverse decision the health insurer will have it reviewed by an independent medical expert who will then decide if the health care service or supply is medically necessary or not experimental if the health insurers decision is to uphold its original decision it must put its reason in writing now at that point you may file a complaint with the Maryland insurance administration for

appeals the life and health unit of the MIAA will investigate whether a service or supply is covered under your health plan and if so whether was paid correctly for grievances the same unit would send the matter to an independent review organization to give its opinion about whether the service or supply was medically necessary and/or not experimental at that point the health insurance decision is found to be wrong

by the MIAA and the health insurer still won't reverse its decision the insurance administration can take action against the health insurer now if you have any additional questions please contact us at one eight hundred four nine two six one one six and thanks for watching