How to Send Medical Bills to Insurance

While healthcare providers typically handle medical billing, you may need to submit claims directly to your insurance company in certain situations. This often occurs with out-of-network care, emergency services where the provider did not bill your insurer, or when you have paid for services upfront and are seeking reimbursement. This guide outlines the steps for successfully submitting a medical claim to your insurance provider.

Gathering Required Information and Documents

Before initiating a claim, gather specific information and documents. Personal identification details, such as your full name, date of birth, policy number, and group number, are found on your insurance card. These details link services to your specific insurance coverage.

Provider information includes the full name of the treating physician or facility, their address, and identification numbers like the National Provider Identifier (NPI) and the Tax ID Number (TIN). The NPI is a unique 10-digit identification number assigned to healthcare providers for identification in transactions. The TIN, often an Employer Identification Number (EIN), identifies the entity responsible for tax reporting and receiving payments.

Detailed service information is also required, encompassing dates of service and specific medical codes. These include International Classification of Diseases (ICD-10) codes for diagnoses, and Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes for procedures and services. An itemized bill from the provider lists each service, medication, and supply with its individual charge. Additional supporting documents might include a referral from a primary care physician if required, or an Explanation of Benefits (EOB) from a primary insurer if submitting to a secondary insurer.

Preparing Your Claim Form

Preparing your claim form requires careful attention to detail to ensure accurate submission. Most insurance companies use standardized forms, such as the CMS-1500 for professional claims (physician services) or the UB-04 for institutional claims (hospital and facility services). Some insurers may also provide their own proprietary forms, which can be downloaded from their official website or obtained by contacting their member services department.

Once the correct form is identified, accurately transfer the gathered information into the relevant fields. For the CMS-1500, enter patient details like your name, address, date of birth, and insurance policy information in designated sections. Include provider NPI and TIN, dates of service, and corresponding diagnosis (ICD-10) and procedure (CPT/HCPCS) codes. For the UB-04, include institutional details such as revenue codes, alongside patient and service information.

Legibility is important, especially for paper submissions, to prevent processing delays or denials. After completing the form, attach the itemized bill and any other necessary supporting documents. These attachments provide the insurer with the evidence needed to process the claim. Before sending, make complete copies of the filled-out form and all attached documents for your personal records, as this can be valuable for tracking or in case of disputes.

Submitting Your Claim

After preparing your claim form and gathering all supporting documents, submit the package to your insurance company. Several methods are commonly available for submission, including traditional mail, online portals, or fax.

When opting for mail, locate the correct mailing address for claims, which is typically found on your insurance card or on the insurer’s official website. To establish proof of delivery, use certified mail with a return receipt requested. This provides a legal record that the insurer received your submission, which can be important if there are questions about timely filing.

Many insurance providers offer secure online portals for electronic claim submission. This usually involves logging into your member account, navigating to a claims submission section, and then uploading the completed claim form and supporting documents. If faxing is an option, ensure you have the correct fax number for claims and retain the transmission confirmation report as proof of submission.

Tracking Your Claim and Understanding Outcomes

After submitting your claim, monitoring its progress is an important step. The time it takes for an insurance company to process a medical claim can vary, but typically ranges from 15 to 45 days. You can check the status of your claim through the insurer’s online member portal or by contacting their member services department directly, often by providing your claim number.

Once the claim is processed, your insurance company will send you an Explanation of Benefits (EOB). This document is not a bill, but rather a detailed statement explaining how your claim was processed. The EOB will outline the total charges from the provider, the amount your plan covered, any discounts applied, and the portion you are responsible for, including deductibles, copayments, or coinsurance. It also provides a breakdown of each service, the date it was provided, and the corresponding costs.

Review the EOB carefully to ensure all services are accurately listed and that the payment aligns with your understanding of your policy benefits. If the claim is paid as expected, you will receive a bill from your provider for any remaining balance indicated on the EOB. If the claim is partially paid or denied, the EOB will include a reason or remark code explaining the decision. Understanding these details is the first step in determining any further actions, such as contacting the insurer for clarification or reviewing options for appeal. Maintaining thorough records of all correspondence and documents related to your claim is recommended.