How to Get Reimbursed by Your Health Insurance

Most in-network providers bill your insurance company directly. You may need to file the claim yourself when you see a provider who is out of network, when a provider asks you to pay up front, or when you are traveling and get care from a provider who does not bill your plan.

Whether out-of-network care is covered, and how much, depends on your plan. Some plans reimburse out-of-network care at a lower level, and some do not cover it except in emergencies. Your plan documents explain the rules.

Insurers need specific details to process a claim. A simple receipt usually is not enough. Ask the provider for an itemized bill, sometimes called a superbill, that lists each service with its codes.

Submit the claim form and documents the way your insurer asks: through the member portal, by mail, or by fax.

Most plans set a deadline for filing claims. Find it in your plan documents (for employer plans, the Summary Plan Description) and file well before it. A claim filed after the deadline can be denied even if the care would have been covered.

For private-sector employer plans, federal rules generally require a decision on a claim for care you already received within a reasonable time and no more than 30 days after the plan receives it. The plan can extend this once by up to 15 days if it tells you before the 30 days end. Payment can take additional time after the decision. If you have not heard back, call member services and ask about the status.

Your insurer will send an Explanation of Benefits (EOB). It shows what the provider charged, the amount the plan allows, how much the plan pays, and how much is your responsibility. It is not a bill.

If the plan approves the claim, payment goes to whoever the plan lists as the payee on your EOB, which is often you if you already paid. The amount reflects your deductible, coinsurance, and any out-of-network limits, so it may be less than what you paid.

If the claim is denied or paid less than you expected, you can usually appeal. Your plan documents explain the process and deadline, and our article on appealing a denied claim walks through the steps. A Prime Health Consultants advisor can also explain how the process works and guide you when you need help.

The federal No Surprises Act protects many people with health insurance from surprise out-of-network bills for emergency care, for certain care from out-of-network providers at in-network hospitals and surgery centers, and for air ambulance services.

If you don't have insurance, or you tell the provider ahead of time that you won't use it, providers generally must give you a good faith estimate. You may be able to dispute the bill if it is at least $400 more than the estimate. You must start the dispute within 120 days of the bill date. The No Surprises Help Desk is 1-800-985-3059.