Your health care provider typically submits claims for medical procedures or services. The claim form will ask for your demographic and insurance information, description of services and associated billing codes that describe the procedure or service, plus provider information and dates of service.
Your pharmacy or specialty pharmacy provider typically submits claims for your prescription medication to your insurance company. Claims submitted by outpatient pharmacies usually require the name of the drug and the National Drug Code number. NDC is a national classification system to identify drugs.
How to file a claim
Determine the type of claim form your insurance plan requires. Most claim forms are available online. If necessary, ask your insurance company’s member services department for guidance.
Follow instructions on the form and include all required information. You might need your health care provider’s National Provider Identifier and/or billing codes for the care you received. Your health care provider can provide that information.
If you need to submit a form for pharmacy benefits, ask your pharmacist for the National Drug Code to include on the claim form.
Check the claim form for completeness and accuracy. Sign the form and include required attachments.
Make a copy of the claim form and all receipts, medical records, etc., for your records.
Submit the form and attachments to your insurance company’s claims department electronically or by mail or fax.
Check your claim status
If your insurance company hasn’t reimbursed you or your provider within six weeks, call the insurance company to check on the status of your claim. The customer service department is the best place to start. Before you call, make sure you have:
- Date of service
- Type of service or name of the drug
- Provider’s name
- Total cost submitted
- Policy number (found on your insurance card)
- Insured’s name
- Insured’s date of birth
Tips for effective communication
Follow these tips to ease communication about your claim or appeal:
Be confident when calling your insurance company. As a customer, you have the right to complete information about your health benefits. Your insurance company’s customer service representatives are supposed to assist you. Part of their job includes answering questions to your satisfaction.
Know your benefits. Many health insurance companies make it deliberately difficult to get comprehensive information about what a plan does or doesn’t cover. Do your best to gather that information through a separate conversation with a customer service representative, your employer or insurance agent.
Be persistent. If you have discussed your request with a customer service representative but you’re not satisfied with how they handled your insurance matter, ask to speak to a supervisor. Or call back another time and discuss your request with a different customer service representative.
Document all communication. Record the date(s) of your conversations and the first and last names of the representative(s) with whom you spoke. Make notes about any information they provided to you. Keep copies of all written correspondence between you and your insurer.
Get help from your employer and/or your medical team. In many cases, your employer makes decisions about what will and won’t be covered under your health plan. Your employer’s support can help your request for coverage get approved. Ask your physician to contact the health insurance company because they can explain the necessity of the procedure or service.
Advocate at all levels. If your health insurance plan isn’t responsive, or if you believe they are breaking the law or their contract with you, get additional help. File a complaint or grievance with your state’s department of insurance and contact your elected official’s constituent services staff.
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