My Coverage Explained

What Is a Health Insurance Claim?

We’ve all done it before: sat in a doctor’s office and filled out form after form with our insurance information. Ever wonder why they need all that info? Well, your doctor’s office needs it so that they can file a claim with us.

What is a health insurance claim? A claim is simply a bill that your doctor or other health care provider will send to an health insurance company (such as Blue Cross and Blue Shield of Illinois) for payment after they have treated you.

In most cases, your provider’s office will submit the claim for you so you don’t have to worry about it. But there are some instances when you may have to file the claim yourself, such as when you get care from an out-of-network provider. Which brings us to the next question: How do you file a health insurance claim?

How to Submit a Claim
I
f you do have to file a claim, here’s what you need to do:

  1. Print out a “Health Insurance Medical Claim Form” from the  Form Finder section in Blue Access for MembersSM
  2. Fill out the form completely. You’ll need to have this information handy:
    1. Date of service/treatment
    2. Type of service
    3. Dollar amount charged by the health care provider
    4. Member ID number (found on your ID card)
  3. Mail the form and the original bill issued by the provider to the address printed at the top of the claim form

Some Tips

  • Make copies - It’s a good idea to make copies for your records because the bill you send in with your claim will not be returned to you.
  • Don’t wait too long - Be sure to file your claim soon after you receive care. This is more important when you have a claim from late in the year and you need to make sure your claim is applied to the right plan year.

Check the Status of a Claim
There are a couple ways you can check the status of your claim:

•    Visit the Claims Center in Blue Access for Members
•    Call the customer service number on the back of your ID card

Blue Access for Members
Please note that the claim will not show up in Blue Access for Members until it is processed. There are 2 types of claims statuses that you will see within Blue Access for Members:

  • Paid – We have paid for the services
  • Processed – Claim is still in the works and no money has been sent out to pay it yet

You can also sign up for text/email alerts to notify you when the status of your claim changes. All you have to do is:

  • Log in to Blue Access for Members
  • Click on Settings at the top of the page
  • Click on Preferences
  • Click the box next to the type of alert you would like to receive under “Alert Preferences”

Explanation of Benefits (EOB) Statement
Once your claim has been processed by us, you will receive an EOB, either by mail or email. This document will break down:

  • The amount billed by your provider
  • Medical benefits that were approved (how much we are paying)
  • Amount you may still owe your provider

If your claim has been denied, you can file an appeal to have it looked at again. The appeals information is located with your EOB.

Still have questions? Ask us in the comments!

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