Health Insurance terms can be very difficult to understand, especially for international students; This is because the United States healthcare system is very different from other countries. One of the very important terms that students must be familiarized with is the term “claims”; this term is very important to know because students will have to file a claim at some point in their stay in the U.S when using health insurance
What is a Health Insurance Claim?
A claim in health insurance is a term used to describe a request for payment that you or your healthcare provider submits to your health insurer when you get items or services you think are covered.
Simply explained, when you go to the doctor, the provider will fill out a form to request coverage of the benefits your health insurance policy has. Sometimes, you will have to file a claim if the provider will not file one for you.
How do I file a claim?
Although this term might sound very scary, there is no need to panic. Filing a claim is simpler than you think. There are four simple steps to file a claim:
- Ask your doctor: Provide your health insurance ID card to your doctor’s office. The claims information will be on your health insurance card such as the claims department contact information. If you are an ISO member, you can access your health insurance ID card attached to the confirmation email you received when you enrolled in the plan or by logging into your ISO member account using your member ID/email and password. ISO’s claims department is Wellfleet. The doctor’s office should typically submit a claim on your behalf using this information.
- Get all claim documents: If your doctor will not file a claim for you, request all the required documents to file a claim from your doctor’s office. You will need an this is a bill with detailed information on what medical services you were charged, this is a useful document you can use to argue what you were charged for and note any incorrect charges. The itemized bill must include the name of the doctor or clinic, date of service, diagnosis code, procedure code, provider tax ID, and total charge of the service.
- Complete the claim form: Fill out the claim form according to the instructions of the form. If you are enrolled in an ISO policy, you are in luck! We provide students with a document that explains in detailed instructions how to file a claim.
- Submit form and documents: File a claim and required documents within 90 days. You will have to submit claims to your health insurance’s claims department. ISO members submit their claims to Wellfleet.
How long does it take for claims to be processed?
Claims are processed within 10-20 business days. Once your claim has been processed you will receive an explanation of benefits (EOB); an EOB is a statement from your health insurance company that describes in detail how you were covered according to your plan’s benefits for the medical services that you received.
Your insurance company may investigate your claim, require additional information,
and verify that eligibility requirements and other terms were met before paying claims.
My claim was denied, now what?
What happens if you received your claim and it was denied, or you received your claim but disagree with the information stated on your explanation of benefits? If this is your case, luckily, there is something that you can do to ensure that you were covered according to your plan’s benefits for the medical services that you did receive or obtain an explanation of why your claim was denied through a process called a claims appeal.
A claims appeal is a process where you request that your health insurance company reconsider the claim denial that you received. Depending on who your health insurance company is, the steps will be different. Some health insurance companies will just need the appeal to be in writing in the form of an email. If you are an ISO member and would like to submit a claims appeal, you just need to email Wellfleet (ISO’s claims department) at firstname.lastname@example.org and provide the reason for your appeal and submit supporting documents and comments you would like to have considered.
Hopefully, this information will ease your claims scares and can help you better understand health insurance. And remember, it’s always good to know who your claims department is and their contact information to help you with questions whenever you need it. Wellfleet’s claim’s contact information can be found here.