Insurance Billing & Coverage Questions

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Resolve Billing & Coverage Questions

Did you get a medical bill that seems incorrect? Have you received a bill for services that should have been covered by insurance or you thought was already paid for? Billing and claim disputes can be stressful – not to mention confusing. If you have a billing or claim problem, or have questions about whether a service or procedure is covered, follow these simple steps:

1. Review Your Coverage

Before you do anything else, take some time to review your current benefits. If you don’t have a lot of time, at least be sure you know the basics – deductibles, coverage limits, networks, and the like.

Smart move: Our Employee Benefits Guide is a great place to start! It summarizes everything you need to know about your benefits, including health, dental, and vision insurance. For additional benefit information, check out HR’s “Employee Benefits” web page.

2. Contact your Provider

Call your provider and confirm they have the correct plan name and group number. Your problem might have occurred because of a clerical error, such as the doctor entering the wrong code. If so, ask the provider to resubmit the claim with any necessary corrections.

It could also be that your provider is not in-network. With an out-of-network provider, you could be charged more because your visit will be reimbursed by the insurer at a lower rate than with an in-network provider. Be sure to verify all persons associated with the service are in-network. For instance, sometimes a hospital is in-network, but some of the doctors (the anesthesiologist, for instance) are not.

Smart move: Some providers send bills before they are processed by insurance. To make sure you pay what you actually owe, wait until you get an Explanation of Benefits (EOB) from your insurance. At that point, you will get another bill from the provider reflecting the insurance payment and the amount you owe. 

 3. Contact your Insurance

Often, the most effective way to address a billing or coverage question is to contact your insurance provider (see list below). When you call insurance, be sure they have received the bill and any other information necessary to process the claim. Common reasons insurance won’t pay a claim are because they need information on other insurance that may apply, the claim was due to an accident, or the claim is work-related.

If you still have a problem with your bill, explain why the bill seems wrong, the steps you have taken so far, and how you would like to have the problem solved. Have any applicable documentation handy, such as the EOB, your bill, and your ID card. Take note of the name of the person you spoke with and the date and time that you called; get a reference number, if possible. If they promise you something over the phone, ask for it in writing.

Complete contact information for all the City's insurers can be found in the Employee Benefits Guide. Below are the most frequently requested claim and customer support contacts:

Smart move: Before calling, be sure you’ve allowed enough time for the claim to be processed – it can take up to 30 days. However, do not wait too long: most providers set deadlines for bill payment and appeals. You should be able to check your insurer's website for information on claim status.

 4. Ask the Experts

It can be frustrating to make multiple phone calls only to wind up right where you started. As a City employee, you have access to HealthJoy, a free benefits app with a slew of great resources. One tool in the HealthJoy app is the Medical Bill Review feature, which provides the ability to have your bill reviewed and any billing questions answered by a third-party expert. 

Healthjoy LogoDownload the free Healthjoy app on the Apple App Store or on Google Play or call a member representative at (877) 500-3212 to try it out.

Smart move: Most major insurers offer online tools that show how much you might owe for common procedures and doctor visits based on your deductible status and plan features. You can also ask your doctor what a treatment or procedure is likely to cost, and several third-party websites are available – try FAIR Health, Clear Health Costs, or Healthcare Bluebook.

 Still Need Help?

If after trying the above steps, you still can’t resolve the issue, contact the City’s independent benefit consulting firm, The Horton Group. You will be asked to provide the following supporting documentation:

  • EOBs, provider bills, member ID number, and date of birth
  • Summary of call with carrier and outstanding issues
  • A signed HIPAA authorization form may be required in certain instances

Kelly Jagelski is the City's representative from The Horton Group.