How to Fill Your Health Insurance Claim Form

Keeping track of family health history and medical recordsUnderstanding coordination of benefitsIncreasing your chances of getting your claim processed the first time around

This post stresses the importance of keeping good med­ical records to make sure that you file accurate claims. This post also explains the standards that determine how insur­ance plans determine which plan pays first. If you have more than one insurer, knowing the order in which to file your claim can save time and money.

With accurate, up-to-date records, filling out the claim form (a request to pay your medical expenses) should be simple and painless. Correct information on the claim form also lessens the chance that the insurance company rejects your claim or returns it for additional information.

For each person in your family, keep a record — in chrono­logical order — of each event related to a particular condi­tion. The record should include enough information to make reconstructing the details of a condition easy for you. Include summaries and dates of pertinent telephone conversations and correspondence. Keep the form in a file folder and add the appropriate paperwork — copies of bills, receipts, corre­spondence, prescriptions, and the like — to the file.

Table 7-1 shows an example of such a record. You can change or add to the categories to reflect your own needs. Fill out the record in diary fashion, entering first the date of the next event with the appropriate corresponding information and notes. Add pages as necessary.

Table 7-1: Troy Family Health Record

Claim Information                           Family Member

Name of patient                                  Helena

Date of birth                                       10/9/54

Social Security number                       111-22-3333

Name of insurance company               Happy Health Insurance

Insurance policy group number           0700-131886

Your insurance ID number                  123-45-6789

Date of service                                   1/1/2000

Diagnosis                                           Flu

Name of provider, correspondent Dr. Gary

Address and telephone number           Dean Medical Center,

for provider, correspondent                 1541 Market; 555-4321

Description of services,                      Saw Helena, prescribed

prescriptions, telephone                      light diet, bed rest

conversations, correspondence

Notes, comments, questions                  Requested medication but

the doctor thought we should wait a day or two

Cost of service                                   $65

Amount you paid                                 $15 copay

Amount submitted to the                     $50

insurance company

How much the insurance                     Nothing: Applied the $50

company paid                                     to the deductible

Balance due                                       $50

Date paid balance due                        2/5/2000

Claim Information                           Family Member

Date                                                   1/5/2000

Description of services,                      Saw Dr. Gary again, who

prescriptions, telephone                      said that Helena didn’t

conversations, correspondence           need any medication; she

looked much better

Cost of service                                   $30 for follow-up visit

And so on

You may also want to keep another set of records for each person in your family that covers health history, showing ill­nesses, injuries, medications, immunizations, and their cor­responding dates. For a complete family history, record your parents’ and other relatives’ health information as well.

The standards also regulate the amounts that each insurer must pay. The primary insurer pays as it normally would for covered charges. The primary insurer then submits a state­ment of the benefits it paid to the secondary insurer before the secondary insurer pays. The secondary insurer picks up the charges for the deductible and coinsurance or copayment. The secondary carrier also pays for benefits covered in the secondary plan but not covered by the primary plan.

If you have more than one health insurance policy, be sure that you understand how the plans will coordinate your ben­efits. Carefully check each plan to understand how and when to submit insurance claims, as well as which plan to send them to first.

The definition of “coordination of benefits” refers to group plans only. Individual plans don’t usually include a COB clause, although every state has its own regulations govern­ing COB with individual plans. In this case, a person with both a group plan and an individual plan who submits the same medical expenses to both plans may receive duplicate benefits. Although this prospect may sound like a good idea, remember that premiums for individual plans are very high, so you may not come out ahead financially.