Health Insurance Claims

Submit the claim form your insurer provides — CMS-1500 for doctor visits, UB-04 for hospital stays — along with itemized bills within your plan's filing deadline. Most in-network providers file claims on your behalf automatically; you typically only need to file directly for out-of-network care or when a provider fails to submit. Your insurer's member services phone number (on the back of your insurance card) can tell you the correct form and deadline for your specific plan.

Source: CMS.gov — CMS-1500 Claim Form

An EOB is a statement from your insurer showing what was billed, what your plan paid, and what you owe — it is not a bill. You receive an EOB after every insurance claim is processed. Compare each EOB against the provider's actual bill to catch billing errors, which are common. The EOB lists the service date, billed amount, the insurer's negotiated rate, the amount your plan paid, and your remaining responsibility (deductible, copay, or coinsurance). Keep EOBs for at least one year after treatment.

Source: CMS.gov — Reducing Patient Burden

Request the denial in writing with the specific plan provision cited, then file an internal appeal within 180 days as guaranteed by the Affordable Care Act. Your denial letter must state the reason for denial and the appeal deadline. Write a formal appeal letter that directly addresses the stated reason, attach supporting medical records and a letter from your doctor explaining medical necessity, and submit by certified mail. If the internal appeal is denied, you have the right to an independent external review at no cost.

Source: HHS — Affordable Care Act Consumer Rights

The No Surprises Act, effective January 2022, prevents you from receiving surprise medical bills for emergency services and certain out-of-network care received at in-network facilities. Before the law, patients could receive large unexpected bills from out-of-network anesthesiologists, radiologists, or assistants at in-network surgical centers. Under the law, your cost-sharing for these services cannot exceed in-network rates. If you receive a bill that appears to violate these protections, contact your insurer or the CMS complaint line.

Source: CMS — No Surprises Act

Write a formal appeal letter citing the specific coverage provision in your plan that supports the claim, attach your doctor's supporting medical records and a letter of medical necessity, and submit within the deadline stated in your denial letter (at least 180 days under ACA rules). Address every reason for denial listed in the denial letter — insurers are required to respond to each point. Request a copy of your complete claim file so you can see all the information your insurer used to make the decision. Track your appeal by certified mail.

Source: HHS — Affordable Care Act Consumer Rights

Collect itemized bills (not summary statements), your doctor's referral or prior authorization documentation, the EOB from your insurer, and any clinical notes supporting medical necessity. An itemized bill lists each service with its procedure code (CPT code) and charge — a summary statement or balance-due notice is not sufficient for claim filing. If your claim was denied for medical necessity, your doctor's clinical notes and treatment history are the most important documents for your appeal.

Source: CMS.gov — Reducing Patient Burden

Insurers must process clean claims within 30 days for electronic submissions and 45 days for paper claims under most state prompt-pay laws. A clean claim is one submitted with all required information and no errors. If your insurer requests additional information, the clock typically pauses until they receive it. Check your state's department of insurance website for your state's specific prompt-pay requirements, as some states have shorter deadlines.

Source: NAIC — Health Insurance

Prior authorization is your insurer's advance approval for a specific procedure or medication — required for non-emergency surgeries, specialist referrals, high-cost imaging (MRI, CT), and many brand-name drugs in most plans. Without prior authorization when required, your insurer may deny the claim entirely or require you to pay out of pocket. Request prior authorization before scheduling any procedure your insurer lists as requiring it. Get the approval in writing with an authorization number before your appointment.

Source: CMS.gov — Reducing Patient Burden

PPO and POS plans cover out-of-network care at a reduced rate compared to in-network coverage — the exact percentage depends on your specific plan — after you meet a separate out-of-network deductible; HMO plans generally do not cover out-of-network care at all except in emergencies. Before seeing an out-of-network provider, call your insurer to confirm your out-of-network benefits and ask what your estimated cost-sharing will be. Out-of-network providers can also balance-bill you for the difference between their charge and what your insurer pays — ask whether the provider will accept your insurer's payment as full payment before the appointment.

Source: CMS.gov — Reducing Patient Burden

Balance billing is when a provider charges you the difference between their full rate and what your insurer paid — the No Surprises Act prohibits this for emergency services and for out-of-network providers working at in-network facilities effective January 2022. For non-emergency out-of-network care, balance billing may still be legal. Before seeing an out-of-network provider for planned care, get written confirmation that the provider accepts your insurance's allowed amount as payment in full. If you receive an unexpected balance bill, contact your insurer to verify whether the No Surprises Act applies to your situation.

Source: CMS — No Surprises Act

Call the member services number on your insurance card and request a pre-determination or benefits verification letter in writing before scheduling the procedure. Ask specifically: Is this procedure covered under my plan? Does it require prior authorization? What is my estimated cost-sharing? Will the procedure be subject to my deductible? A verbal benefits quote is not a guarantee of payment — always request written confirmation. Keep the reference number from your call in case coverage is later disputed.

Source: NAIC — Health Insurance