HOW TO FILE AN OUT-OF-NETWORK MEDICAL CLAIM

Howtofileanoutofnetworkclaim

Is your doctor out-of-network?  Does your doctor not accept insurance?

If so, here is a quick step-by-step guide to submitting a medical claim to your insurance company for reimbursement!

Again, this is not legal advice--just advice based on my personal experience.

1.  OBTAIN A SUPERBILL FROM YOUR PROVIDER--If your doctor does not automatically provide you with a "superbill" or routing slip, ask for one! If you didn't get one at the time of your appointment, call the office and have them send you one.  In addition, keep a copy of your credit card receipt.

2.  COMPLETE YOUR INSURANCE COMPANY'S MEDICAL CLAIM FORM--Your insurance company will have a form (sometimes called a medical claim form, other times called a health claim transmittal form) that you need to submit in order to submit your medical claim for reimbursement. 

Usually, you can find this if you log into your insurance provider's online portal.  You can also call the service number on the back of your insurance card and they will direct you to the right form.  Do not just google "Aetna Medical Claim Form"! The same insurance provider (i.e., UHC or Aetna) may have different variations of the form depending on your plan.  Make sure you are submitting the correct one!

3.  WRITE A LETTER--Write a letter to the insurance company at the address you are required to submit the medical claim form.  A simple example letter might read:

Re: Medical Claim Form Related to Services Rendered by [Dr. XYZ] on [Date of Service]                         Member: [Name]                                                                                                                                                Member ID No.: [#]                                                                                                                                               Group No: [#]                                                                                                                                                    Provider: [Name of Doctor]                                                                                                                                     Date of Service: [Date You Were Seen by Doctor]                                                                                            Amount Billed: [$ Amount You Were Charged]                                                                                                                                                                                               To Whom It May Concern,

Attached please find a signed medical claim form related to serviced rendered by Dr. XYZ on [Date of Service].  In addition, please find a copy of the related superbill and credit card reciept in the amount of [$].  As set forth under the terms of my plan, please reimburse me for this cost and credit my account and deductibles accordingly.

                                                                                                    Sincerely,

                                                                                                    [Patient Name]                      

Enclosures:                                                                                                                                         

  1. A signed copy of the Medical Claim Form dated [X]
  2. A copy of a superbill for services rendered by Dr. XYZ on [date].
  3. A copy of a credit card reciept dated [X] in the amount of [$]

4. MAKE LABELS AND STICK ON EVERY PAGE--Make labels that include the information set forth below:

Member: [Name]                                                                                                                                                    Member ID No.: [#]                                                                                                                                               Group No: [#]                                                                                                                                                           Date: [Date ]                                                                        

Put this on EVERY SINGLE PAGE.  Yes, even the page with the copy of the receipt.  Yes, even pages that might already have that information. Note, do NOT cover up any words or information. 

If you can't find a blank space, put the sticker on the back (and make a double sided copy).  The reason I do this is because sometimes insurance companies require you to put this information on every page you submit, but often this requirement is in teeny, tiny writing in some obscure place - don't give them any excuse to deny your claim!  As an additional perk, it will make your life easier if you have to appeal because your forms and documents will be more organized and better labeled (trust me, the dates and forms get mixed up pretty quickly).

5. MAKE HARD COPIES AND SCAN--Once you have signed the letter, put labels (or written that information) on every page, verified that you have completed the correct form and have the correct address, make a copy of the entire package.  File that away somewhere safe.  I prefer to create a binder, but will do a separate post on that!  In addition, scan the entire package into a single PDF so that you can easily access an electronic version.

5. FOR BEST RESULTS, SEND CERTIFIED MAIL--Sending your medical claim form and supporting documentation via certified mail is not necessary.  Perhaps it is just the lawyer in me who is a bit risk averse, but sending certified mail just rids the insurance company of the excuse that they never received it.  Keep the signed green form when you get it back and file it away!

I hope this was helpful!

If you have any other tips or suggestions, please write me!

A special thank you to my mother and two little birdies from the office who help me coordinate to send all these things out!

Kristal Lyme and the City


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