How to File a Claim for Medical Bills with Health Insurance

The primary reason for acquiring any insurance policy is to relieve your mind of any stress and concern. The irony of life is that our minds are always overwhelmed or obsessed with countless concerns and uncertainties regarding the complexities of insurance policies. Similar is the case with health insurance policies and their provisions, which are highly appealing to purchase but not easily understandable to the average health insurance customer. A terrible question may run through your head, wondering whether or not your health insurance policy would cover your medical expenditures. Some other questions may also pop up in your head asking how to claim medical bills with health insurance.

If you are likewise perplexed with the “whether” and “how” of health insurance plans, this article can undoubtedly assist you. All you have to do is read the entire post because we will go over everything you need to know about claiming medical expenses with health insurance.

Notable Considerations

It goes without saying that the insurance company creates the provisions for your health insurance. As a result, it is highly recommended that you thoroughly review the terms and conditions of your health insurance plan before purchasing it. Otherwise, you’ll constantly be subject to concealed situations that could jeopardize your advantages. It has long been observed that each insurance company has its own hospitals or physicians on its panel. As a result, you must carefully analyze the provisions of your health insurance plan. When you visit a doctor or a hospital, you must show your health insurance card or the relevant information about it.

Consider the following considerations before delving farther into the procedure of obtaining your medical bills paid through your health insurance.

Does Health Insurance Pay Medical Bills?

The most popular question is whether or not health insurance coverage cover medical expenses, and the most accurate answer is simply yes. Of course, your medical expenditures will be covered by your health insurance. It is frequently done in two ways. Buyers of health insurance would choose between Indemnity Plans and Defined Benefit Plans. Indemnity health insurance policies strive to reimburse medical expenditures after you have made a payment. Defined Benefit Plans, on the other hand, are designed to pay you a defined amount in the event of a specific disease. As a result, it is not an exaggeration to claim that your medical expenditures can be covered by your health insurance.

The Medical Illness Situations not Covered by Health Insurance

Certain disorders are frequently omitted from the list of those for which health insurance would either pay a fixed sum or refund the expenditures. For example, a condition that did not manifest itself until the date you purchased your health insurance policy. Similarly, if you have a genetic issue, a preexisting ailment, HIV, or another congenital disease, the domestic and indigenous methods of treatment or homoeopathic treatment are usually not covered by health insurance coverage.

In addition to that, your health insurance plan will also not serve you in case of non-life-threatening diseases. For instance, if you are undergoing cosmetic surgery, dental treatment, or joint adjustment. Moreover, It also doesn’t cover the medical expenditures that you may bear in case of childbirth, pregnancy, or vaccination. Nonetheless, some insurance providers offer health insurance coverage for pregnancy after 2 to 4 years of the starting date of the plan. However, your health insurance plan will reimburse the medical bills after 2 to 4 months of the commencement of the plan.

How to Reduce Medical Bills with the Right Health Insurance Plan?

Apart from any doubt, healthcare is the chief concern of all US citizens that can never be compromised in any case. Nonetheless, the medical expenses are soaring in the sky and are not easily affordable for a common person with an average monthly income. However, they can be considerably reduced to some extent by choosing the right health insurance provider. Here we are going to disclose some tips for selecting the right health insurance plan to reduce your medical bills.

1. Go for the Preferred Provider Option (PPO) Health Insurance Plan

If you are visiting some physician or hospital that falls outside the network of your health insurance provider, then you are significantly less likely to cut your medical expenditures. It is because the health insurance provider would pay a very negligible amount for your medical expenditures when you use a hospital outside of their network. On the contrary, if you choose a Preferred Provider Option health insurance plan (i.e., you visit a hospital/doctor on your insurance provider’s panel), your health insurer will pay the majority of your medical bill (about 70-80% of the entire bill).

2. Search and Scan the Internet to Find the Most Affordable Option

At present, many US-based websites are serving as “infomediaries” and provide you with helpful information regarding the affordable treatment of a particular disease in a specific hospital. You can easily search the affordable solution or treatments for your disease provided by your preferred doctor or hospital. Therefore, an online search and public reviews for the various medical service providers will enable you to make the right choice to reduce your medical bills somehow.

3. Approach a Professional Healthcare Advocate

Some local healthcare advocates in your area can also help you find the cheapest yet most effective solution for your medical needs. He can surely assist you in finding better options for affordable medical treatment and will also resolve any billing issues or other complications in the health insurance policies.

4. Avoid the Name-Brand Drugs

As the pharmaceutical companies in the US have no restrictions on running advertisement campaigns, you will come to know a lot of well-known pharmaceutical brands. However, it is advisable to use generic prescription drugs because they are as effective as name-brand drugs.

5. Create a Health Saving Account

A health saving account may help you save your medical expenditure as the amount you save in this account will remain tax-free if used for some qualified medical treatment cause. Thus if you establish a health savings account, then you can probably save a considerable share of your health expenses.

How to Claim Medical Bill with Health Insurance

Let us explore the process of claiming or filing the medical bill from the health insurance company.  Basically, there are two types of claim processes for your health insurance. It is wise to know about both and choose the easier one. This ultimate guide will give us a comprehensive insight into how medical billing works with health insurance.

1. Cashless Claim

As the name suggests, it doesn’t require you to pay any bills (your health insurance covers that) at the time of admission or discharge from the hospital. First, to understand the cashless claim, consider that many health insurance providers have tie-ups with various hospitals on their panel. You can easily see on your policy document that they mention a long network list of hospitals working in collaboration with your health insurance provider. In order to get your medical bills paid by your health insurer, follow these useful steps.

Bring Your Health Insurance Documents

Never forget to bring your health insurance documents with you to the hospital. It involves various documents and cards which clearly mention your plan and its coverage options as well. Sometimes, people visit the hospital in some emergency situations and forget to bring their documents with them. So it is advisable always to keep your health insurance documents ready with you so that you can use them in any urgent case scenario.

Claim through Online Application

However, you can also use the online application of your health insurance provider. At present many health insurance companies have launched their online applications, which can help you in accessing your information or navigating the status of your plan from anywhere.

TPA Desk

Go to the Third Party Administration (TPA) Desk, and they will process all the documentation in coordination with your health insurance provider. They will verify and confirm your plan and its provisions.

Initial Approval

Once the TPA desk verifies your insurance document’s authenticity by consulting the health insurance provider, now the focal person of the TPA Desk would inform the health insurer of the estimated duration and expenditure of your medical treatment. The health insurance company will give initial approval to start the medical treatment.

Final Approval

At the time of discharge, the TPA Desk will again approach your health insurance provider and ask him about the payment for your medical bills by sending them all the medical records and receipts. The health insurance company will review the case and verify all the proofs. It will respond soon with the final approval for the payment of the medical bills. Normally, the turnaround time of the health insurance companies is 30 minutes to 4 hours.


Nonetheless, there are some items for which your health insurance company would not compensate. Therefore, you have to make payment for those non-payable items, but that is not very important.

2. Claim for Reimbursement 

In this case, first, you have to pay for your medical bills, and then you will apply for a refund of the payment of your medical bills. It is a little complicated process where you are supposed to show a series of original documents. Keep in mind that photocopies of the original documents would not work because the insurer may think that you have also claimed it to some other health insurance provider as well. However, you can request for the return of original documents once they verify them. This is because you may also require your original medical treatment documents for some important purpose.

Claim through the Digital Application

You can also file your claim through their digital application. You have to provide all the original receipts of medical bills, reports of the tests, a list of the prescribed drugs and such other things related to your medical treatment.

Claim the Reimbursement for Pre & Post Hospitalization

There are also some provisions in your health insurance policy regarding the pre and post hospitalization expenditures. However, different health insurance providers have different provisions on it. It may, for example, cover your medical expenses ahead to your admittance to the hospital for surgery. It will also cover the costs of your follow-up visits. As a result, you can gather all of the documents from before and after hospitalization, as well as those from during the hospitalization time, and register your claim as a group.

Turn Around Time

The turnaround time of the various health insurance companies for reimbursement claims usually is 3 to 4 weeks. However, if they need some pending information, then they will ask you to submit that as well. You may have a disagreement with your health insurance provider to reimburse your medical expenditures if you created fraudulent documents or gave inadequate information. Nonetheless, if you have provided the original documents with nothing missing, then your medical bills will be reimbursed quite soon.

Apart from the above mentioned two processes of claiming the medical bill from your health insurance, there is also a third one as follows:

Pre-Authorization Treatment

You inform your health insurer prior to your medical treatment in such a case. For example, if you have to undergo open-heart surgery, you may visit your health insurance company and inform them about your surgery. It will save you from visiting the TPA Desk time and again. However, there is a 7 to 10 days validity period for pre-authorization treatment. Moreover, you are supposed to get your treatment done by some hospital in their network list.

Final Thoughts:

To summarize, you must understand the importance of your healthcare and be concerned about preserving it in cost-effective methods. Your health insurance plans can help you greatly in any health emergency situation. However, you are required to be equipped with the necessary information and knowledge of getting coverage for your medical treatment or claiming reimbursement for the medical bills you have paid to the hospital. Therefore, knowing how to claim medical bills with health insurance can truly reduce your medical bills.

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