Claims Process for Health Insurance

• August 30 2018
• |   Insurance

Typically, with the health insurance claimed by the medical provider of the hospital or doctor, they submit the bill, and you’ll go and get treatment. You will probably get a medical bill from them which explains the services and the cost of the services. You also get an explanation of the benefits (EOB)s, which is the explanation that is sent by the health insurer to the patient explaining to them or the insurer, what was covered, the discount, what insurance needs to pay, and if there is a co-payment or deductible.

Q: Do they have a timeline wherein they have to pay or deny within a time period?

They are supposed to pay within 30 days. The health insurer or administrator may request an additional 20 days but must specify the reason why additional time is needed.

Q: If they were to ask for additional information, how much time do they have to make the request?

The insurer can request additional information within the 30 days but they must specify the reason for why additional information is needed. The insurer can then have an additional 20 days to accept or deny the claim.

Q: Do you ever find or suspect that an insurance company is delaying on purpose?

We often see situations where the insurance company ask the same questions over and over again to delay payment of the claim. The insurance company is always happy to accept the premium payments from the insured, but the insurer delays and drags out paying claims. This conduct is obviously to the detriment of the people the insurer has a contract with.