Tips for Successful Claims

Feeling Overwhelmed?

Hospital bills, Doctor's bills, and medical bills in general can be confusing to understand. For more complex procedures you may receive bills from multiple sources. It can be easy to get overwhelmed. When it comes to getting your health claims processed, it is important to understand the process.

Process for tracking your claims

We have assembled the following steps to help you take control of your medical claims. By getting engaged and following this process you can minimize the confusion.

  • Don’t wait, or it can make resolving a claim issue complicated.
  • The first thing you receive is the doctor or hospital bill, keep it but do nothing.
  • You will then receive the EOB, (Explanation of Benefits), from your insurance company showing the original charge from the provider, discounts applied, and disallowed charges, if any. Then a total allowed amount and how it applied to your office copay, deductible, and/or coinsurance. After meeting your deductible and coinsurance the plan will pay the allowed amounts at 100%.
  • The EOB will tell you what portion of the charges you owe based on your meeting the deductible and coinsurance. Know your deductible and coinsurance.
  • Remember that if you use a non-network provider, you will be subject to the additional out of network deductible and coinsurance limits. Additionally, you are responsible for the total amount the doctor billed, regardless of what the insurance company dictates as the Reasonable & Customary dollar amount they will pay the doctor for that service.
  • If you see a charge was not covered, look at the reference code next to that charge on the EOB, and check the code reference guide on that EOB to see why it wasn’t paid.
  • Call the membership phone number on your medical ID card, and ask to speak to the Claims department. It’s helpful to jot down the phone rep’s name and the date when you speak to them.
  • Ask them to explain the reason the code used by your provider was not approved.
  • If the charge was not paid due to the code that was used, call the doctor’s office and ask them to confirm that the correct code was used. If not, ask them to re-submit the bill with the corrected code and to include doctor notes from that visit.
  • Claims are often declined subject to a request for additional information from the doctor or hospital. That is where you get involved by contacting the provider to send what information was requested to the insurance company to get the claim paid.
  • You will then receive a final adjusted bill from the doctor or hospital. Don’t pay the provider more than the correct EOB states you owe them. Their bill should show the same discounts and amounts paid by the insurance company as the EOB from the insurance company. If the numbers are not the same, call the provider and ask them why not.
  • If you feel the payment or nonpayment of the claim is just wrong, appeal the claim. You have 60 days after the denial a.k.a. the date the EOB was sent to you.

You are not Alone

Some times an ongoing treatment creates a flood of bills.  We are here to assist you when you need it. Sullivan & Associates offers additional services to its customers to assist them through the complex processes.

You want a partner who understands your objectives, defines and presents the options available, discusses the short and long term affects in making decisions and works in your best interests on a consistent basis. Sullivan & Associates has maintained the highest degree of integrity and confidence in building a relationship based on trust for over 25 years.