Health insurance companies usually have their own claim forms

To ask the insurance company to pay your providers or to reimburse you if you have already paid your providers you submit a claim form. Each health insurance company usually has its own claim forms that it provides to members.

Sometimes insurers accept forms directly from a health care provider’s office as long as the forms include all the information necessary for processing the claim. If you belong to an HMO or a PPO, you probably don’t need to fill out a claim form for office visits or hospitalization. You simply show your member card. If you’re a member of a PPO and use a provider outside the network or if you have a feefor- service plan, you probably do have to complete a claim form, although sometimes your health care provider fills out the claim form for you.

When you fill out a claim form, a couple of paragraphs in fine print require your signature. One of these paragraphs is the assignment of benefits. When you sign the assignment of benefits, you authorize the insurance company to pay claim benefits directly to the health care provider. If you already paid your provider and want the insurance company to reimburse you, don’t sign the assignment of benefits.

Claim forms indicate what information you need to fill in and which information your provider needs to enter. The patient or policyholder usually fills in the following information:

• Name of policyholder, address, and Social Security number
• Name of the insurance company, group number, and the policyholder’s ID number
• Patient’s name, address, date of birth, sex, and relationship to the policyholder
• Patient’s marital status and work status (employed or student)
• Employer’s name and phone number
• Whether the claim is due to an injury; if so, date of injury and whether the injury occurred at work
• Name, address, and phone number of other insurance company covering patient
• Whether the patient has Medicare coverage
• Signature to authorize release of information and assignment of benefits

When you sign the authorization to release information, you’re giving the insurance company the right to get any and all information relevant to your claim from your health care providers.

Either the patient (or policyholder) or the health care provider may have to fill in the following:

• Date of first sign of illness, or date of accident
• Date of previous instance of same or similar illness
• Dates the patient is unable to work in current occupation
• Name and ID number of referring physician
• Hospitalization dates

The health care provider usually fills in the following:

• Diagnosis or nature of illness or injury
• Dates of service, procedures, and charges
• Federal tax ID number
• Patient account number
• Whether the provider accepts assignment of benefits
• Amount paid and balance due
• Provider signature and date

Double-check that all information you enter on the claim form is legible and correct. Sign and date the form. Make a photocopy for your records and attach copies of itemized bills and/or receipts. (Photocopies are important, especially if the claim is lost and you have to resubmit it.) Bills and receipts must include the patient’s name, date, service, and charge. If the receipt is for a prescription, it must also include the prescription number, the doctor who ordered the prescription, and the pharmacy’s name and address. Mail the claim form and note the date you send it to your insurance company. Send all your bills to the insurance company, even if you don’t think they’re covered.

If you have an expense that you can apply to your deductible, the only way to get credit for that expense is to send the bill to the insurer. Check your insurance plan carefully for the claim submission deadline usually 90 days from the date the charges are incurred. If you submit your claim after the deadline, the insurer won’t consider your claim. After the insurance company receives your claim, it sends you an Explanation of Benefits (EOB) or Explanation of Medicare Benefits (EOMB) to let you know how much it will pay. For each procedure you submit through your claim form, the COB shows the fee that the insurance company allows. If the company doesn’t pay a benefit on a procedure, the EOB gives the reason for denying benefits. You may appeal a claim if you disagree with the amount paid.