Why Won’t You Pay My Claim???

I have spent a few months looking at claims and how people submit them into Benecaid, where I currently work.  Submitting manual claims can be a very frustrating experience for those not living inside the insurance world.  Paperwork, mailing addresses, originals versus copies - it can be a real headache.  That being said, I thought I would share some of the biggest mistakes people make when submitting claims to an insurance company.

1. Original Receipts & Prescriptions

This is by far the biggest issue for customers.  You should always send the original receipt and if you have it, a copy of the prescription to validate that it was prescribed by a doctor.  The second item isn’t always necessary but is handy to ensure faster processing.  If you want a copy for your records, keep the photocopy AND NOT the original.  The insurance provider or HSA adjudicator will question the copy and most likely return it to you.  After all, if they received a copy, how many other companies did you send the copy to?

2. Use The Right Form

With so many forms, it is hard to stay on top of which one to use.  Every insurer or HSA provider should have the forms readily available on-line.  If you are unsure which form to use, your best bet is to call your insurer or HSA adjudicator once a year and ask.  Download and print a couple and keep them on file.

3. Complete the form in FULL

Many insurers have standardized forms designed to be scanned to retrieve the data and convert it into an electronic format.  This technology is used to speed up the processing and is designed to be a benefit for the customer.  When you do not complete the form in full, or enter information in the wrong place, it can cause problems in scanning and slow-down the adjudication of your claim.  Take your time and complete the form in full.  Most insurers and HSA adjudicators have reference guides you can ask for if you need help…just ask them for a copy.

4. Send Your Claim to The Right Address

Be sure to send your original claim and the correct completed form to the right place.  Many insurers and HSA providers have more than one location for adjudicating claims.  If you are unsure of where to send your claim, call their customer care department before you send it.  It can save you problems down the road.

5. Coordination of Benefits

If you are already covered under another plan (i.e. company plan or spouse’s plan), the insurer will most likely ask you to submit your claim to the first insurer before you submit it to them.  They will cover anything not covered from the other plan up to your maximum.  If you have an HSA, it is always wise to send the claim to your insurer first.  When you receive the claim back, the difference can be taken out of your HSA.  To do this, you simple forward the original Explanation of Benefit (EOB) received from the original insurer with a claim form.  The HSA adjudicator will take the amount unpaid from your insurer and reimburse you the difference from your HSA.  While it is a complex process, it does save you money in the long-run from your HSA.  After all, if you already have insurance through another source and it is not costing you anything, you should take advantage of it!

These tips are not going to ensure that every claim is paid but it will help to make the process faster and ensure proper adjudication.  If you follow these tips, you should see a significant reduction in follow-up with your insurer or HSA to find out…”Why won’t you pay my claim?”