Insurance Claims: How Are They Processed?

Navigating health insurance claims can feel daunting, but understanding the process can help you to make a more informed decision about what coverage to get and how to make the most out of it. 

Whether you're planning a routine check-up or facing unexpected medical treatment, knowing how to properly manage your health insurance claims ensures you receive the care you need while maximising your benefits.

What is a health insurance claim?

A health insurance claim is a formal request you submit to your insurance provider seeking reimbursement for medical expenses you've incurred. Think of it as presenting a receipt to your insurer, asking them to cover the costs of your healthcare treatment according to your policy terms.

When you receive medical care, whether it's a consultation with a general practitioner (GP), a specialist treatment, or a hospital procedure, you can submit a claim to your insurance provider and, based on the coverage you have, request for them to pay or reimburse the procedures. The claim serves as documentation that proves you received legitimate medical care that falls within your policy's coverage parameters.

Your health insurance claim should include important details such as the type of treatment received, the healthcare provider who delivered the service, the cost of treatment, and any supporting medical documentation. This information allows your insurer to verify that the claim meets policy requirements and determine the appropriate reimbursement amount.

What can I claim from my health insurance?

The scope of what you can claim depends entirely on your specific policy, but most health insurance plans cover a broad spectrum of medical services. Understanding your coverage helps you plan your healthcare decisions and avoid unexpected out-of-pocket expenses.

Most policies cover consultations with general practitioners and specialist doctors, including follow-up appointments, vaccinations, and routine health screenings. Diagnostic procedures such as blood tests, X-rays, MRI scans, and other imaging services typically fall under standard coverage, though some may require pre-authorisation.

Hospital treatments, including both inpatient and outpatient procedures, are generally covered; they encompass surgical procedures, emergency care, and specialised medical interventions. Many health insurance policies also include coverage for prescription medications, although this coverage may be subject to a formulary or specific approval processes.

Complementary treatments such as physiotherapy may also fall under the coverage of some plans, albeit with specific limitations or referral requirements.

It's important to review your policy documents carefully or speak with your insurance provider to understand exactly what's covered, as exclusions and limitations vary significantly between different plans and providers.

What is the claim process like?

The insurance claim process follows a structured pathway designed to ensure proper verification and payment of legitimate medical expenses. Understanding each step helps you navigate the system efficiently and avoid common issues that could delay your claim.

Check your eligibility

Before seeking treatment, verify that your policy is active and that the specific treatment you need qualifies for coverage. Check whether you've reached any annual limits, whether the condition is subject to waiting periods, and if pre-authorisation is required for your intended treatment.

Contact your insurance provider or check your online portal to confirm your current coverage status. This preliminary step can save considerable time and prevent claim rejections due to policy limitations or lapses in coverage.

Visit your GP or specialist

When seeking medical care, inform your healthcare provider that you'll be paying via insurance co-payments and/or submitting an insurance claim. This ensures they provide the necessary documentation required for your claim submission.

Your healthcare provider can help with insurance claim requirements and may assist with the documentation process. Some providers may offer direct billing arrangements with your insurer, which can streamline the entire process.

Gather documentation

Collect all relevant documentation immediately after receiving treatment. This includes detailed receipts, medical reports, diagnostic results, prescription details, and any referral letters. Ensure all documents clearly show the date of service, provider information, and specific treatments received.

Retain both original documents and photocopies for your records. So, if you lose any original paperwork during the claims process, you can use digital copies as backup documentation.

Submit your claim

Complete your insurance claim form thoroughly and attach all the required supporting documentation. Many insurers now offer online submission portals or phone applications that can expedite processing times and provide immediate confirmation of receipt.

Submit your claim as soon as possible after receiving treatment, as most policies have time limits for claim submissions. Late submissions may be rejected regardless of their validity.

Choosing your healthcare provider

Whenever possible, it's advisable to choose healthcare providers that are recognised by your insurance provider, as this can help to ensure that your claims are processed more smoothly.

If you choose a doctor or specialist who works in multiple hospitals, this may affect your coverage and reimbursement rates. You may face higher out-of-pocket costs or additional administrative requirements.

Treatment and payment

Depending on your policy and provider arrangements, you may pay upfront and seek reimbursement, or your provider may bill your insurer directly. Understanding your payment obligations beforehand helps you plan financially for your treatment.

Keep detailed records of all payments made, including any deposits or co-payments, as these may affect your final reimbursement amount.

Follow-up and further treatment

If your treatment involves ongoing care or follow-up appointments, please make sure each subsequent claim is accurately documented and submitted. Chronic conditions or long-term treatments may require periodic reauthorisation or updated documentation.

Monitor your claim status regularly and respond promptly to any requests for additional information from your insurer to avoid processing delays.

For details about the claims process for your policy, please contact your insurance provider directly. If you would like to confirm whether your insurance is accepted at Thomson Medical, our medical concierge can assist with further information.

What should be taken note of in insurance claims?

Several common mistakes can delay or result in the rejection of your health insurance claim. Being aware of these potential issues helps ensure your claims are processed smoothly.

Missing documentation or incomplete forms

Incomplete claim submissions are among the most frequent causes of processing delays and rejections. Insurance companies require specific information to verify and process claims, and missing even minor details can halt the entire process.

Ensure all forms are completed thoroughly, with no blank fields left unfilled unless specifically marked as optional. Double-check that all supporting documentation is included and that medical reports clearly indicate the diagnosis, treatment provided, and associated costs.

Pay particular attention to date formatting, provider information, and policy numbers, as errors in these critical fields often trigger automatic rejections that require resubmission of the entire claim.

Not checking eligibility or pre-authorisation before treatment

Many insurance policies require pre-authorisation for certain treatments, particularly expensive procedures or specialists' consultations. Failing to obtain the required pre-authorisation can result in the claim being denied, even for treatments that would otherwise be covered.

Review your policy terms carefully to understand which treatments require prior approval, and contact your insurer well in advance of scheduled procedures to secure necessary authorisations. Keep records of all pre-authorisation communications and reference numbers.

Some treatments may have specific eligibility criteria, such as requiring a GP referral before seeing a specialist or meeting certain medical criteria before accessing particular treatments.

Using non-approved providers

Insurance policies often specify networks of approved healthcare providers who have negotiated rates and streamlined billing processes with the insurer. Using providers outside this network may result in reduced reimbursement rates or additional administrative requirements.

Before scheduling appointments, confirm that your insurance company recognises your chosen healthcare provider and comprehend the potential consequences of using non-network providers. Some policies may cover non-network providers at reduced rates, whilst others may not cover them at all.

Emergency situations may have different rules regarding provider networks, but for planned treatments, using approved providers typically ensures optimal coverage and fewer complications.

What happens after a claim is submitted?

Once you've submitted your health insurance claim, it enters a review process to verify the legitimacy and accuracy of your request. Your insurer will first acknowledge receipt of your claim, typically within a few business days of submission. This acknowledgement usually includes a claim reference number that you can use to track the progress of your claim.

The claims assessment team will then review your submission, checking that all required documentation is present and that the claimed treatments fall within your policy coverage. They may cross-reference your claim against your policy terms, previous claim histories, and any pre-authorisation records.

If additional information is required, your insurance provider will contact you directly with specific requests for supplementary documentation or clarification. Responding promptly to these requests helps maintain the processing timeline and prevents unnecessary delays.

Upon completion of their review, your insurer will make a decision regarding your claim. If approved, they'll process payment according to your policy terms, either directly to your healthcare provider or as reimbursement to you. However, if your claim is rejected, they'll provide a detailed explanation of the reasons for denial and information about any appeal processes available.

Most insurers provide online portals or mobile applications where you can track your claim status in real time, receive notifications about processing milestones, and access important documents related to your claim.

For further information about health insurance claims at Thomson Medical, please contact our medical concierge.

FAQ

How long does a typical claim take to process?

Processing times vary depending on the complexity of your claim and your insurer's procedures and may take 2-3 months.

What if my claim is rejected?

Who can I contact at Thomson Medical for help with claims?

What are the most common health insurance claims?

The most frequently submitted health insurance claims typically include routine medical consultations, prescription medications, diagnostic tests, and preventive care services. GP consultations and specialist referrals account for a significant portion of claims, reflecting the importance of primary healthcare in overall health management.

What are the 4 stages of insurance claims?

How quickly can you claim on insurance?

Disclaimer: The information provided is intended for general guidance only and should not be considered medical and financial advice. For personalised recommendations and tailored advice on pricing and services, contact us at Thomson Medical today.