Home / Health Insurance / What to Do If You Haven’t Gotten Your Health Insurance Reimbursement

What to Do If You Haven’t Gotten Your Health Insurance Reimbursement

Published: April 28th, 2020

Reviewed by Diane Omdahl

At HealthCare.org, we strive to create easy to understand content that will help our readers navigate their health care options. We adhere to strict editorial standards. This post may contain links to lead generation forms, which is how we make money. However, this will not influence our writing. The content of this page is accurate as of the posting or update date. Read more

There are times when an insurance company won’t pay a claim as quickly as you would like. Whether it’s a prior authorization requirement or a medical coding error, we may all have to deal with a delayed insurance claim. 

At some point, most of us will have to submit a claim to our health insurance carrier for a treatment or procedure we paid for out-of-pocket. And most of us will wait for months on end to be reimbursed. Health insurance claim delays are not only frustrating–they can threaten policyholders’ financial security and ability to access necessary medical care.

medical devices page break image

Unfortunately, having medical coverage also means dealing with inefficient payment systems, increasingly complex and confusing reimbursement requirements, and overworked health insurer employees. Knowing how to properly contest a claim payment decision is key to maintaining your sanity and your financial health.

Most of us don’t have enough time or patience to wrangle with an insurer about payment. The guide below includes tips on how to deal with a delayed insurance claim. Here’s how you can navigate the claims process, minimize hassles, and get all the money you’re owed.

What Is an Insurance Claim?

A health insurance claim is a formal request for reimbursement which consumers submit to their health insurance carrier. A health insurance claim form should contain the following information:

  • Name of the planholder;
  • Name of the insurance company;
  • Policyholder and group ID number;
  • Whether the injury or illness is work-related;
  • Date of the medical service;
  • Services and/or procedures that were carried out;
  • Corresponding medical codes;
  • Itemized charges for each treatment or procedure.

After receiving this formal request for reimbursement from a policyholder, insurance companies review the health insurance claim, check for errors and inconsistencies, and confirm that the medical services listed match the medical and diagnosis codes indicated on the form. Assuming the insurer finds no issue with the policyholder’s claim, the insurance company then goes ahead with a health insurance reimbursement to the policyholder for the amount he or she paid up-front and out-of-pocket for medical care.

What Causes a Delay in Health Insurance Claims?

Unfortunately, health insurance companies can sometimes be slow when it comes to processing health insurance claims. In some cases, a delay in a health insurance claim is the result of an insurer investigating a claim and deciding that it doesn’t fall within the health plan’s scope of coverage. But in other cases, delays are the result of miscommunication. Because every health care plan has its own internal billing guidelines and coding procedures, information doesn’t always flow swiftly between providers and insurers. And patients with Preferred Provider Organizations (PPOs) will probably need to file their own claim when they use an out-of-network provider.

Follow These 5 Steps to Follow Up on Your Delayed Insurance Claim

1. Identify Why Your Claim Was Delayed 

Let’s say your claim was sent back to you for additional information or returned to your healthcare provider. What can you do if your retroactive refund takes longer to process than you had hoped it would?

Most delayed claims are not due to malicious intent on the part of the insurer, but rather are the result of a coding mix-up or administrative error. If you submitted a health insurance claim form to your insurer months ago and have yet to hear back or receive payment, your first step is to figure out why there’s a holdup.

2. Dealing with a Delayed Insurance Claim: Make a Few Phone Calls

Planholders are often frustrated with how long it takes their insurance company to respond to their requests for coverage–and understandably so. A solutions-oriented mindset can go a long way in rectifying the situation. Start with a phone call.

  • Call the Doctor or Hospital: If you’re questioning a hospital charge or a bill from a physician’s office, you may be able to ask the doctor herself about the charge or you may have to start with someone in the billing department who can work on it for you. Whatever you do, keep calling until you get the right person on the line.
  • Call Your Insurance Company: If you’re dealing directly with your insurer, call your insurance company to inquire about the status of your health insurance claim. On the first call, a customer service representative must collect your information and confirm your identity before resolving the issue at hand. Do your best to be patient and courteous. Health insurance claims representatives handle angry, upset policyholders all day–they are more likely to be helpful to someone who is polite and respectful.

If the customer service representative with whom you speak is uncooperative or unhelpful, ask to speak to his or her supervisor. Persistence will get you everywhere.

3. The Importance of Documentation

If you’re waiting on a delayed insurance claim payout, it’s important that you take notes of all phone conversations and interactions with the insurance company, including the:

  1. Date and time of the phone call;
  2. Names of the people with whom you spoke; and
  3. A description of what was discussed

In the insurance world, documentation is king. If your insurer’s customer service representative offers to make an adjustment to your bill, ask that they confirm their offer to do so in writing (or via email).

4. If Your Claim Is Denied, File an Appeal

Nobody wants to learn that their request for payment for care they’ve already received, has been denied. But there are steps which consumers can take to maximize their odds of filing a successful health insurance claim appeal and recouping what they spent on care.

5. Stay Organized

When dealing with a delayed claim, useful information can be found on your explanation of benefits (EOB). This information includes:

  • Your Claim Number: Each health insurance claim is assigned a unique number so it can be identified in an insurer’s system. Though it may be possible to locate claims without this number, it is much more difficult and time consuming. Make the customer service representative’s job easy–have your number accessible!
  • Healthcare Provider Details: Have the name, address, phone number, and physician license number of the doctor whose claim is in dispute. In some cases, the provider listed may be a company, rather than an individual.
  • Dates of Care / Service: Some medical services are provided over a series of visits, even though they are billed as a single service. Have the exact dates at your avail. It is also helpful to know when the claim was sent to your insurer by the provider.
  • Network Status of the Provider: Your appeal will be much stronger if your providers are included on your insurer’s list of in-network providers.

Delayed Insurance Claim? Follow Up. Then, Follow Up Again.

Follow up with your insurer on a regular basis to check the status of your delayed insurance claim. Be persistent, calm, and explain that you intend to pursue the issue until it is resolved and the claim is paid.

Getting payment for a delayed claim can take many months to resolve, so call your insurer often and take notes of each call.

Delayed Insurance Claim? Know Your Rights.

  1. Prompt Pay Laws: Many U.S. states have “prompt pay” laws requiring insurance companies to pay health insurance claims within a specified number of days — usually it’s 30. That said, the rules governing a delayed insurance claim often differ in each state.
  2. Insurers Must Not Prioritize Own Financial Interests: The law also specifies that health insurance companies cannot put their own financial interests above that of their policy holders

Taking the Next Steps

Whatever the situation, a delayed payment – especially in the form of health insurance reimbursement – can at best be a minor hassle and at worst a financial burden. Make sure you know who to reach out to in these situations. If you’re having issues with your current coverage, we can help you look elsewhere.

If your delayed claim turns into a denied one, you may choose to appeal.

Share this article