About Health Insurance Claims


Health Insurance claims are standard forms used by medical billers. These forms are submitted to health insurance companies by individual doctors, practices or facilities seeking payment for medical services rendered to a patient. Upon receipt, these forms are processed by the health insurer's claims department. Each billed charge is reviewed to determine if it is payable. Charges approved for payment are then paid to the provider or facility either in full or at an agreed upon rate.


There are two types of health insurance claims. Professional charges are billed on a HCFA 1500 claim form. Professional claims include charges for services rendered by a physician. Services performed during an office visit, such as blood work and x-rays, may be billed as separate charges from the visit. Facility claims are called UB92 forms and are used for charges incurred by a hospital or other medical facility where the services were performed. Facility charges include costs for such things as emergency room visits or surgeries.


Health insurance claims include a patient's name, address, social security number, date of birth and insurance information, such as the name of the health insurer and the patient's identification number. They also include the date(s) that services were provided and the name of the doctor or facility that provided the services. The exact procedures that were performed are represented by standard codes called Current Procedural Terminology (CPT) codes. Each CPT code corresponds to one or more International Classification of Diseases (ICD-9) codes. The billed amount for each procedure is also indicated, as well as the provider's tax identification number.


If you have health insurance, it is better to see doctors that accept your health insurance plan. These doctors are referred to as "in-network" or "participating" and are responsible for submitting health insurance claims to your insurer. Out-of-network or non-participating providers may require you to pay upfront for services, causing you to take on the responsibility of submitting a claim to your insurer. If you choose to see an out-of-network doctor, obtain a completed claim form from them for you to send to your insurance company. Participating doctors should not ask you to pay anything up-front other than your co-payment.


Health insurance claims have a filing time frame. In general, claims are to be received by an insurance company no more than one year from the date of service. Participating doctors usually have a more stringent time frame to submit their claims. Claims can be denied for untimely filing. Also, charges that are not submitted on a proper claim form may be denied consideration for payment until they are resubmitted on the proper form. Health insurance companies receive thousands of claims everyday from medical billers. These claims are itemized and all the charges to be processed are listed separately. However, when patients submit claims to their health insurer, they may not include all of the pertinent information needed for the claim to be considered for payment. Therefore, knowing about health insurance claims is important.