Use this generic claim form as a reference.
You have insurance, but your provider wants to be paid that same day. If the provider did not, or will not, submit a claim (the form sent to your insurance carrier to request payment for services on your behalf) you are not out of luck!
Situations where the doctor or other healthcare provider (such as a vision center, dentist or chiropractor) asks you to pay your bill at the time of care are fairly common, especially when the provider is out-of-network or runs a small practice. (Out-of-network means that the healthcare provider does not contract with or directly accept your particular insurance plan.)
Should you still want to be reimbursed by your insurance company (according to your benefit plan), you will need to file a claim on your own. Here is what you will need to do to recover a portion of your costs:
Step One: Having the right paperwork with complete information is key! Make sure you have a copy of the receipt from the provider proving you have paid for the medical care. Without this receipt, the insurance company is not likely to reimburse your claim.
Step Two: The insurance company will need a copy of the itemized bill. (This will be supplied by the provider.) If you did not get a bill at the time of service, you should be able to call and receive one after the fact. Be sure to keep a copy for your records and make sure the bill includes this information:
- Date(s) of service (the day(s) you went to the doctor or hospital)
- Diagnosis code (sinus infection, strep throat, etc. – listed on the bill as a number such as 461.0)
- Description of services (what they did when you went to the doctor – blood work, eye exam, etc.)
- Procedure codes for services (these are the numeric codes that represent the services, ex: 99214)
- Provider name (make sure to include the doctor’s name even if you went to the ER or a clinic)
- Provider address (their physical address or the address for their billing department)
- Provider tax identification number, license number or National Provider Identifier (NPI)
Step Three: Most carriers require a claim form. On your insurance companies’ website, search for a term such as “filing a claim” or “claim form.” If you cannot find a claim form, call your insurance company or your plan administrator and ask them to fax or email you one.
On the claim form, make sure to include your name, member ID number, and a daytime telephone number where you can be reached. Make sure you also include a copy of both sides of your insurance card.
Step Four: Mail the bill and receipt with the above information to the address on the reverse side of your member ID card. If you are unable to find this information on your card, check the insurance carrier’s website.
Note: If there is any additional information you need to complete for the claim, expect the insurance carrier to send it back flagged with the items you are missing or need to correct. Upon approval, payment will be made to you based on the coverage in your benefit plan.
*** Make a complete copy of everything you send, and do not hesitate to call and follow-up! ***
