Tips for claims problems and billing

In most cases, physicians, hospitals, and other providers will file claims directly with your health care organization. If they are participating or contracted with your plan, then payment will be sent directly to the provider. If the provider is not contracted or non-participating, they may still file a claim on your behalf but you are responsible for paying the provider for the services and your health care organization’s payment will be sent to you.

Even if the provider files the claim, you may still receive a bill. There are several reasons why you could receive a bill.

Specialists or other “behind the scene” providers (e.g. laboratories, radiologists, etc.) may not have your health care coverage information.

Tip: If this appears to be the case, then call the billing information number on the statement, give them your coverage information and ask if they will file the claim.

The provider is non-contracted or non-participating with your plan, so they are looking to you for payment. Or you may have paid for services while on vacation or when outside of your plan’s service area.
The bill may be for a copayment, co-insurance, or deductible amount that is your responsibility.
This may only be a statement giving the most recent status of your account with the provider.
The bill may have mistakenly or inadvertently been sent. (Even sophisticated computer billing systems and good billing staff have been known to have bills released and sent out in error.)

So what should you do if you receive a bill:

First, look for a statement that says “this is not a bill”. If the statement has this notice, just keep this statement for your records.
Check the bill for a notice that the claim was filed with your health care plan. The notice may state: "Your insurance company has been billed. " If they are not requesting a specific payment then it is just a copy for your records.
Check to see if there is a specific amount due. If there is no dollar amount or it's all zeros, you're not being asked to pay. Keep this copy for your records.
Carefully review all the information on the bill for other instructions. The provider may be instructing you to send the bill to your health care plan.

TIPS FOR FILING YOUR OWN CLAIM

Check the back of your health plan member identification card (or your plan’s member handbook) for the address and any instructions for filing claims.

Make sure all of the following information is included on the bill or an attached separate sheet:

Identify that you are a member of the plan
Note patient’s name and identification number (or include a copy of the ID card)
Patient’s current address and phone number
Provider’s name and address (if it does not appear on the bill)
Date of each service and reason for service (if this information is not stated on the bill)
If you paid for the service and the claim does not indicate such payment, then include a copy of your receipt or cancelled check if possible. (Do not send original cancelled checks.)
Brief description of any other information that may be helpful (e.g. you paid for service while on vacation, reason you thought you needed the service if it was an emergency or urgent service, etc.)

Note the date you are submitting the claim, in case further follow-up is later needed.

If possible, keep a copy of the claim and any accompanying information you filed.