Student Cover’s Guide to filing health insurance claims in the US: Part 1 – For US Based Company

A student health insurance is as good as its ability to cover the medical expenses effectively as promised to the customer. International students studying in various universities and colleges in the US are mandatrily required to either enroll themselves to a student health insurance plan (SHIP) sponsored by their institution or purchase an alternative private health insurance from the market.

But buying a health plan is only a part of the process of securing oneself. In the event of an illness or injury that requires one to undergo treatment, one should know how to receive insurance benefits under his/her insurance plan so as to get the treatment cost covered by the provider. In this 2 part blog series, Student Cover guides you through various processes and procedures involved filing health insurance claims. In part 1, we try to explain the steps involved in claim process for plans purchased from American health insurance companies. Click here to go to part 2 of the blog series.

Types of Claim settlements

A claim can be settled in two ways namely, through direct settlement and or through reimbursement of the cost of treatment.

DIRECT SETTLEMENT – This facility is provided mostly in hospitals or medical institutions that are ‘in-network’ providers. In such institutions the insured only needs to pay the out-of-pocket expenses incurred during treatment. These out-of-pocket expenses include deductibles, co-pay and co-insurance. For the remaining cost of treatment, the hospital or medical institution contacts the health insurance company which eventually pays the amount as per the plan.
CLAIM REIMBURSEMENT – Those hospitals and medical institutions that are ‘out-of-network’ providers do not directly bill the health insurance provider. The insured in these cases has to fill and submit the claim form himself or herself with the health insurance provider. The health insurance company then processes the claim and reimburses the insured as per the terms of the plan.

Step 1: Inform the Health Insurance Provider

While insurance companies provide health cover, they have to be informed by the client if he or she needs their services. Each health insurance company has a department dedicated to registering and processing insurance claims by the clients. They also have a 24/7 helpline number to assist clients. For example, the helpline number for all Student Cover health plans for international students in US colleges and universities is 1800 5270218. A student can call up the helpline and seek assistance with regard to coverage, network hospital in the nearby area as well as documents required to process the claim.
One should have his or her health card handy as it contains most of the information including the type of plan, the coverage period etc. that is sought by the health insurance provider.

Step 2: Collect the relevant receipt

The claim process requires the claimant to provide details of the medical expenditure incurred during treatment. For this, it is essential for the insured person to collect the itemized receipt of the expenditure. This receipt has information on each and every service availed and procedure performed on the patient during treatment. What is significant about this is that it not only contains information on the cost but also the pre-assigned code for each service. This helps the health insurance company reimburse the client accordingly. One can receive the itemized receipt from the hospital or medical institution where he or she received treatment.

Step 3: Download or fill the claim form online/offline

All health insurance companies provide claim form to the clients which have to be filled as per the instructions. It requires a patient to provide

a. Personal information such as Name, Gender, Date of Birth, Mailing Address, Email ID and Health Card ID number or policy number.

b. Information about the injury or sickness such as date of injury/sickness, type of accident (in case of an accident), the attending physician’s name and address etc.

c. Out-of-pocket expenses such as co-pay, co-insurance, deductibles already paid by the insured.

Step 4: Send or mail the information

After filling the claim form, the insured needs to send scanned copy of the documents email or post them to the insurance company. For the claim to be processed properly, they should send all the relevant documents such as receipt of any amount already paid as out-of-pocket expenses, itemized receipt procured from the medical institution as well as receipt of payment of treatment cost (if bill was paid upfront).

Note: In addition to the above mentioned documents, international students studying in the US may also be required to send a copy of their passport, visa and I20 form.

Step 5: Follow-up

Once the information is sent to the health insurance company, it will be processed by the company and the insured will be intimated in due course of time about the status of his or her claim. However, claimants can also call or send an email to the company to inquire about the status.

Step 6: Processed Claim and reimbursement

After processing the claim, the company sends the insured person an explanation of benefits (EOB) which will inform him or her about the treatment and procedures covered or not covered by the health plan. The company may ask the insured to pay the amount that is due to be paid to the medical provider if he or she has not made an upfront payment of cost other than the out-of-pocket expenses. After it is done, the company will reimburse the insured.

Let’s Wrap Up!

Filing a health insurance claim is not as complicated as it looks. One has to follow basic steps in order to get reimbursed. In case the insured seeks treatment from an ‘in-network’ provider that directly bills the cost to the health insurance provider, one need not have to do much of paperwork. However, to get reimbursement for treatment undertaken at ‘out-of-network’ provider, one can follow the above mentioned steps.

Click here to go to Part 2 of the blog series.

Disclaimer: This blog was written based on the personal research of the writer. Readers are advised to exercise discretion and read the insurance document, its terms and conditions before taking purchasing any health insurance plan. Student Cover will not be liable for any wrongful interpretation of the content of this blog.