How are claims processed?

• Forms are submitted to the insurance company that covers the plan, where they are reviewed for accuracy, coverage, and to assure that they are legitimate.
• An automated billing system prints bills every 30 days according to an established cycle.
• Usually, you are provided with a statement (Explanation of Benefits) showing the date and type of medical service that was provided, the total bill, the amount allowed for payment under your coverage, and the amount for which you are responsible to pay.
  

What if I experience problems with a claims settlement?

• After a second bill for the same service is received, it may be necessary to take action to prevent damage to your credit reputation and/or status.
• Call the number that is listed on your billing statement and speak with the person who initially processed your claim.
• Call your primary physician and speak with the person who submitted your claim. Give them your medical information again if necessary.
• Contact your insurance company within a week to check the status of your claim.
• If your claim is not satisfactorily resolved by the above actions, contact the representative who previously helped you with your insurance policy.
• Remember that federal privacy law severely limits those who may have access to your medical information.
  

What is the law concerning health insurance?

• Although there are many laws regulating health insurance, one of the most important is the federal Privacy Law that restricts access to your medical information by third parties. Commonly referred to as The Privacy Rule, this law became effective on April 14, 2001. There are severe penalties for violation of this law, which was established to regulate health care providers and to protect the privacy of health information of individuals.
• Because of The Privacy Rule, insurance agencies are unable to obtain medical information directly from sources to assist you in obtaining treatment, filing claims, and obtaining settlement payment of medical bills that you incur.
• Another federal law, entitled “Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA),” provides for the continuation of company health care coverage under certain circumstances in order to preclude any exclusions or limitations for pre-existing health conditions.