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Question of a Reader:
If you use a health insurance claim form, how does it work? Why is a health insurance claim denied sometimes?

Christine Heart

Thank you for this question.

A health insurance claim is a bill for the health care services that the provider for the health care refers to the insurance company for payment. Once you see a doctor, the claim for your insurance commences. Your insurance company will only pay the benefits that are covered by your policy. Better make sure that research should be done first to avoid any disputes or misunderstandings upon settlement with the doctor or when you buy medicines at the store. Ask your insurance representative anything that needs clarification. Policy should be read thoroughly so that the coverage may be studied well. This is vitally important especially when a treatment is needed and is not included in the policy.

After the payment, the doctor will send the bill to the insurance claims processing center. This processing center will gather all the important information from your doctor like the information sheet of the patient, health insurance claim forms and the documentation of the proper services. These claim forms is compared with the stated insurer’s benefits to check if the policy covers such services. If it meets the requirements, the insurance company will send the payment for such remaining balance. If it does not, you will have to pay the balance left after your co-pay.

The process is easy as most claims processes are very smooth, but there will also be some denied claims of health insurance. Such claims happen because the plan does not cover the actual procedure, or the medication or supply or the insurance company decides that it is unnecessary or experimental. You may even turn the denial of the claims to acceptance by calling the insurance company before the doctor’s visit and even reviewing carefully your policy.

So every time you go to a new physician, you just need to fill out long forms with all the insurance information, and then give out your insurance card to the receptionist.

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