INTRODUCTION

This guide is meant to teach you how to successfully submit correct and complete claim information to your insurer. It will cover medical, dental, prescription, and durable medical equipment. I will say a few words about medical supplies, also, such as those used for post-surgical care or for some chronic medical conditions.

What qualifies me to write this book? I am a licensed insurance sales person, in the health, accident and life lines. I also have several years’ experience in the claims department of a large insurer of medical and dental policies. It was there that I saw the claims sent in by policyholders that were lacking basic information so necessary for processing. (More about that later.)

I saw claims that did not have the insured’s policy number on them, and the patient name was something common like Thompson or Taylor. Sometimes there was an incomplete or incorrect policy number - which was even worse. It would go under somebody else’s policy until the system questioned why a date of birth did not match up.

Claims came in with good information about the services rendered, but we did not know which family member was the patient. Could it be the senior John Johnson or little Johnny Johnson? There is nothing to tell the processor which it is, as no birth date is provided. Who is “Maggie” when there is no Maggie or Margaret on the policy? Oh, here’s a note on the back page of the policy that Marsha goes by the name Maggie.

Claims came in with only a receipt for a total fee, no breakdown information given. In that case, we need to know if the $256 was for the office visit, an x-ray, or was some part for the office visit and part for the x-ray?

By using this reference as your guide when preparing your claims for mailing to your insurer, you can avoid the many pitfalls and errors that are often made. You will save yourself much aggravation, and you will get a speedier reply to your submissions. You may even sleep better at night.


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On the one hand, it is unfortunate that the masses have been thrust into the position of being their own insurance billers. Medical providers and insurance companies pay very decent money to professionals to fill out (and examine, at the claims end of the claim game) your medical, dental, and equipment claims. You are not paid to do this job, you are not trained to do this job, and yet, because of the many changes in the insurance landscape, the powers that be decided that in return for a discount on your medical services, the providers will not deal with the time-consuming process of filing claims.

That leaves you to do the job. Did anyone help you learn how, or even where to find an impartial source of information? No, they did not. That leaves you stressed out by repeated letters from the insurer for more information before they will pay the bill, and you harassed by bill collectors and bad credit ratings.

I admit that before I got into the insurance industry (and that was quite by chance), I had the same negative image of the insurance field as any one of you. It seemed like a scam, betting against yourself. It seemed like they enjoyed toying with the policy-holder - kind of like the evil Catbert in the Dilbert cartoons who toys with company employees.

And yet once I got behind the scenes, so to speak, I learned that insurance is possibly the most regulated business in America. True, many of the laws were in response to rampant abuses in the past. But those laws are there to protect you and all the insurers in your state have to abide by them. You may think that the agent droning on and on in your kitchen is trying to beat you into submission, but he is obligated to tell you the whole spiel about a product so that you cannot claim you were inadequately informed. The agent has rules about how many days he has to deliver the policy to you, about explaining it to you again when he delivers it, about getting your signature when you and he are in the same physical space together, about keeping up with continuing credits in order to keep his license, etc.

Do you stop to think how almost every other business offers you inducements to buy, but not insurance? That is because it is illegal for the agent to offer you anything of value (in some states a value of $15 is the threshold) but practically speaking the agent can offer you exactly nothing to buy. You buy a car, you can have salesmen throwing thousands of dollars at you in rebate, a new TV and/or DVD player - one time the salesman tried to throw in a vacation on top of everything --- but the poor insurance agent cannot even give you a restaurant certificate or gas for your car.

So, yes, the insurance industry has to operate within very clearly defined parameters that vary with each state. Try to drop the adversarial attitude.