Health insurance claims can be confusing for even the savviest consumer. Most of us are unclear about the inner workings of our health insurance plans and the claims process. However, it is important to know what to expect during the health insurance claims process so that you can protect yourself from incurred costs associated with denied claims. There are several types of claims, and some are smoother to process than others. In this article, we will examine the claims process for both simple and complex health care claims.

First let's look at how a simple health care claim, a regular doctor visit, is handled. If your health insurance plan is like most, you probably have a co-pay for doctor visits. The co-pay is the amount of the bill that you are responsible for paying. For the sake of example, let's assume that your co-pay for doctor visits is $20 and the total bill from the doctor is $100. After you pay your $20 co-pay the doctor's office submits the remaining $80 bill to the insurance company processing center for payment. The insurance processing center collects needed information from the physician, i.e. intake forms, services documentation, and patient information sheets, and pays the claim. Most claims are processed smoothly and are as simple as paying your co-pay.

However, there are instances where processing a health insurance claim becomes tricky and the consumer must navigate the process of being denied coverage and the appeals process. If you are denied coverage on a health insurance claim that you believe should be covered by your health insurance policy, you have two options of appeal, internal and external. The first step in appealing a denied claim is to make an internal appeal directly with your insurance company. Often, you can address the reason for the denial directly with the insurer rather quickly. Insurance companies often deny claims for information errors that can be corrected by working with the insurance company and your physician.

If you find that an internal appeal to the insurance company is insufficient, your next step is to contact your state insurance commission and begin the process of filing an external claim. Every state is different and has a different process by which health insurance appeals are reviewed and decided upon. For this reason, it is important to contact your state insurance commission directly and speak with a knowledgeable employee about the specifics of your state's appeal process. Most states will allow you to make an appeal directly to an expert independent board that will make a decision about your claim denial. If the board agrees with your appeal, your insurer is forced to reverse your claim denial.