This article covers several topics and potential questions about claims, click the links below to jump to a specific topic.
- What is a claim?
- How can I avoid filing a claim?
- When do I need to file a claim?
- How do I file a claim through SimplyInsured?
- I've just submitted my claim. When will I get reimbursed?
- My claim was denied. Can I appeal this decision?
What is a claim?
A claim is a request for reimbursement that you submit to your insurance carrier when you were charged for services or items (prescriptions, medical equipment, etc...) that you believe are covered by your current health plan.
Claims can be submitted to your insurance carrier by you, your health care provider, or your insurance broker.
How can I avoid filing a claim?
The easiest way to avoid filing a claim is to have your provider or pharmacy submit the bill directly to your insurance carrier. This way your insurance will cover everything they owe and you will just pay the leftover balance.
If you have recently applied for health insurance and don't have a member ID yet, you can have your provider or pharmacy send you a bill. Once you receive your member ID and proof of insurance, you can contact your provider or pharmacy to re-submit the bill to your insurance carrier.
You can learn more in one of our other articles in our Help Center. Here is the link:
When do I need to file a claim?
There are several cases where you may want to file a claim with your insurance carrier. These include:
1) When you are incorrectly billed.
For example, if your bill states that your insurance only covers a certain portion of the service you received but you believed that it was covered in its entirety.
2) When you are charged for services (Doctor’s/Specialist’s visit, etc.) or items (prescriptions, medical equipment, etc..) that should be covered under your health insurance plan.
For example, if you need to pick up a prescription but the pharmacy is requiring you to pay up front
3) When your Member ID number is not available. Your member ID number may not be available if your insurance application was submitted after your effective start date and is still being processed by the insurance carrier.
For example, if your effective start date is 05/01/2018 and your application was submitted to your insurance carrier on 05/10/2018 for a May 1st start date then your ID cards would not be available yet because your application would still be processing. If you needed to see the Doctor or pick up a prescription, for instance, on May 13th then you have two options. One, you can have your provider or pharmacy bill you and then you can return your ID number would not be available to you yet.
Note: In order to get your issue resolved and to get reimbursed in a timely manner, your claim must be filed within 30 days of the date you received the service or item that you're requesting reimbursement for.
How do I file a claim through SimplyInsured?
This process is made simple and easy on your SimplyInsured dashboard.
STEP 1: On your employee dashboard you can click "Submit Claims" under the "Benefits" section.
STEP 2: You will then be taken to this page to submit your claim:
- The next step involves inputting all the information regarding your claim. Make sure to fill in every section and attach any files relating to your claim, such as, receipts, invoices, bills, and any other related paperwork.
STEP 3: You will be taken to this page that shows the timeline of your claim request.
- You will also receive an email from the SimplyInsured Support Team to confirm the submission of your claim request with your insurance carrier.
If you have any additional questions or concerns, you can contact Support@simplyinsured.com for further assistance.
I've just submitted my claim. When will I get reimbursed?
After your claim has been submitted, it takes about 8-10 weeks for your insurance carrier to process, approve, and send your reimbursement. The insurance carrier will contact you if any additional information or documentation is needed to process your claim.
Note: Though SimplyInsured can submit the claim on your behalf, your insurance carrier will reach out to you directly with updates and will not follow up with SimplyInsured.
My claim was denied. Can I appeal this decision?
If your claim has been denied, SimplyInsured can help you submit an appeal. Make sure to forward all correspondence with your insurance carrier to firstname.lastname@example.org so we can further assist you in getting this issue resolved.
Note: Though we can appeal the claim, there is no guarantee that the insurance carrier will reverse their decision.
If you have any questions about this, please submit a request to our customer care team at the link below: