When you receive medical care, you usually pay the provider (doctor, hospital, therapist, etc.) your share of the bill. You expect your health insurer to pay the rest of the bill. To get that payment, the provider files a claim with your insurer.
But sometimes you may have to file a claim with the insurer yourself. This could happen if you see an out-of-network provider or if the provider doesn’t accept your insurance.
If you need to file your own health insurance claim, here’s what you need to know:
How do I file a claim with my insurer?
You’ll find a claim form on most health insurers’ websites, along with information on how to submit the claim. Look at your health insurance card for your insurer’s website or a phone number to call for information about filing a claim.
What will I need?
You will need the following to file a claim:
- An itemized bill from your health care provider. Ask the provider for this. The bill should include the date you received care and a list of services you received with the provider’s charge and a description and/or billing code for each service.
- Your personal information, including your social security number, your health insurance ID number, and, if you received medical care due to an accident or illness at work, your employment status.
- Whether to send payment directly to the provider or to you. If the insurer sends the payment to you, you’re responsible for paying the provider.
When do I file the claim?
File the claim as soon as possible after you receive the medical care. Many insurers have a deadline to file a claim, such as no more than 90 days after you receive care.
Where do I submit the claim?
Look for an address on the claim form. If it’s not there, check the insurer’s website and the back of your health insurance card or call your insurer.
What happens after I file the claim?
After you file the claim, the insurer has a limited time to tell you if it will pay the claim. How long the insurer has varies by state. After the insurer reviews the claim, it will send you an Explanation of Benefits or EOB. If the insurer is paying the claim, it will send the payment as you directed, either to the provider or to you.
Your health care provider may send you a bill before the insurer has reviewed the claim. If so, call the provider’s billing office. Ask to delay payment until after the claim is processed. Check the EOB to know the correct amount you owe the provider.
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