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What you need to know about filing a health insurance claim

Most often, when you see a doctor or need health care services, the provider you see files a claim with your insurance company. You pay your portion and then the doctor's office handles the rest. 

However, there may be times when you need to file a health insurance claim yourself. This means you need to let your health insurance company know what services you received, where and for how much. You may need to pay your copay, coinsurance or deductible for the service at the time and then your insurance company will reimburse you for covered portions. 

When and how to submit a health insurance claim

When you receive care within your plan's network, the service provider handles the filing for you. But sometimes you may need to go outside your plan's network or receive services from providers that don't file with your insurance. To make things easier, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has detailed instructions and forms for filing insurance claims yourself.

Out-of-network care

One of the most common reasons you would need to file your own claim is if you visit a doctor or service provider who is outside your plan's network. Some plans provide coverage for out-of-network care, often at a higher deductible or co-insurance rate. If your insurance plan does cover out-of-network care, you'll need to work with the doctor, lab or specialist to receive the proper documentation. 

You can ask your doctor for a detailed receipt, often called a "superbill," that lists the procedure codes for each service you received. You'll then file the charges for each procedure code. The insurance company may pay you back for some of the costs incurred or apply those costs toward your out-of-network deductible. 

Care when traveling

When you receive care outside the United States or on a cruise ship, you'll need to submit your own health insurance claim for reimbursement. This is because most health insurance companies have specific forms to fill out for international travel. Make sure to have a detailed, itemized receipt from the health care provider that lists all services performed and the cost.

Vision care or prescription products

Some service providers for vision care, prescription drugs or durable medical equipment may be covered under your plan, but they might not file claims with your insurance. You can submit a claim with your insurance to get reimbursed for some or all costs for these products or services.

Additional considerations

You should rarely need to file a claim yourself, especially if you see providers within your network. It's important to understand what's covered under your plan and what's not, so you know whether you need to file a health insurance claim at all. 

In general, preventive care, essential health benefits, in-network care and medically necessary services are covered. Cosmetic procedures, experimental or investigational treatments as well as services not described in your benefits summary are not covered. Not all plans cover out-of-network care, so before filing a claim, check if your insurance offers this coverage. 

If you have any questions about the process, call the number on the back of your health insurance card.

Patricia Chaney

Patricia Chaney


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