How Long Does Health Insurance Have to Pay a Claim?

Health insurance claims are formal requests submitted to an insurance provider for payment of medical services received. Understanding this process helps policyholders anticipate when their medical bills will be resolved and what steps to take if issues arise.

Standard Claim Processing Timeframes

A health insurance claim is ‘clean’ when it is complete and accurate, containing all necessary information for the insurer to process it without requesting additional details. This includes correct patient demographics, provider information, dates of service, procedure codes, diagnosis codes, and any required supporting documentation. Submitting a clean claim helps ensure prompt payment and reduces delays.

Prompt payment laws, enacted at federal and state levels, dictate the maximum timeframes within which insurers must process and pay clean claims. These laws ensure healthcare providers receive timely reimbursement, supporting the financial stability of medical practices. All states, except South Carolina, have prompt payment laws setting specific deadlines.

Federal regulations for programs like Medicaid generally require 90 percent of clean claims from practitioners to be paid within 30 days of receipt, and 99 percent within 90 days. For most commercial health insurance, prompt payment laws typically mandate processing within 30 to 60 days. This timeframe usually begins when the insurer receives the claim and ends when it is paid, denied, or additional information is requested.

The method of claim submission significantly impacts processing speed. Electronic claims are processed faster than paper claims due to automation. Electronic submissions often resolve within 15 to 30 days, with some automated systems processing claims even faster. Paper claims can take longer, typically 30 to 45 days, sometimes up to 60 days, as they require physical handling and data entry.

Factors Influencing Claim Processing Duration

Several factors can extend the time for a health insurance claim to be processed beyond standard timeframes. Errors or omissions in the claim submission are a common cause for delay.

Missing or incorrect patient information, such as an incorrect insurance ID number or date of birth, can prevent a claim from being recognized as clean. Inaccurate or outdated medical coding for diagnoses and procedures can also flag a claim for review.

Incomplete or missing documentation also contributes to processing delays. Insurers may require supporting medical records, detailed doctor’s notes, or specific test results to verify the necessity of services. A claim might also be delayed if required pre-authorization was not obtained prior to treatment.

Claims involving coordination of benefits can take longer to process. This occurs when a policyholder is covered by more than one health insurance plan, requiring insurers to determine which plan is primary and secondary. Each insurer must then coordinate payment, adding complexity and time.

Claims requiring medical review for necessity often experience extended processing times. An insurer may need to evaluate whether a treatment aligns with established medical guidelines or is considered experimental. In rare instances, if a claim is suspected of fraud or misrepresentation, it can undergo a thorough investigation, significantly prolonging the payment process.

Addressing Claim Delays or Denials

When a health insurance claim is delayed or denied, policyholders can take specific actions to resolve the issue. The first step involves checking the claim’s status, often through the insurer’s online portal, mobile application, or by calling customer service. These platforms provide real-time updates on a claim’s progress.

Upon receiving a decision, policyholders should review the Explanation of Benefits (EOB) or denial letter. An EOB is not a bill but a statement from the insurer detailing covered costs, what the policyholder might owe, and reasons for any denial. This document is essential for understanding the insurer’s decision and identifying the specific reason for denial.

If a claim is denied, policyholders have the right to initiate an internal appeal with the insurance company. This involves formally requesting the insurer to reconsider its decision. The appeal should include supporting documentation, such as medical records, a letter from the treating physician explaining medical necessity, and a copy of the EOB or denial letter.

Insurers are generally required to respond to internal appeals within 30 calendar days for pre-service and 60 calendar days for post-service. Policyholders typically have 180 days from the denial notice to file an internal appeal.

Should the internal appeal be unsuccessful, policyholders can pursue an external review. This process involves an independent third party, not affiliated with the insurer, reviewing the denied claim. External reviews are often facilitated by state regulatory bodies or through a federal process, particularly for denials based on medical necessity. Standard external reviews are typically decided within 45 days, while expedited reviews for urgent cases can be resolved within 72 hours.

Throughout the process of addressing delays or denials, meticulous record-keeping is advisable. This includes documenting communication dates, names of representatives spoken with, and maintaining copies of all submitted forms and correspondence. Contacting the State Department of Insurance or relevant consumer protection agencies can also provide assistance during complex claim disputes.