Medical Claims FAQ
Employer-Sponsored Medical Benefits
Most medical claims are submitted directly by your healthcare provider to your insurance carrier. However, there are situations where you may need to submit a claim yourself. The information below outlineshow member-submitted medical claims work under employer-sponsored medicalplans.
When would I need to file a medical claim myself?
You may need to submit your own medical claim if
- You paid for services upfront and need reimbursement
- An out-of-network provider does not submit claim forms to insurance
- A claim was not submitted correctly or needs correction
If your provider is in-network, they typically handle claim submission for you.
How do I submit a medical claim?
Follow these steps:
1. Request an Itemized Medical Bill
Ask your provider for a detailed itemized statement that includes:
- Date(s) of service
- Description of services performed
- Charges for each service
- Provider name and address
- Provider Tax ID and NPI number
- Diagnosis (ICD-10) codes
- Procedure (CPT or HCPCS) codes when available
2. Obtain the Correct Medical Claim Form
Visit your medical insurance carrier’s website and download the medical claim form. This may be labeled as:
- Prescription/Rx Claim Form
- Member Claim Form
- Medical Reimbursement Form
- Direct Member Reimbursement (DMR)
3. Complete the Claim Form
Provide all required information, including:
- Member ID and group policy information
- Patient details
- Provider information
- Coordination of benefits if you have other coverage
- Accident-related information if applicable
Incomplete forms may delay processing.
4. Submit Your Claim
Submit the completed form and itemized bill using your carrier’s preferred method:
- Online member portal
- Secure upload
- Mail or fax to the address listed on your ID card or claim form
5. Keep Copies for Your Records
Maintain copies of all submitted documentation, including:
- Claim forms
- Itemized bills
- Receipts
- Supporting paperwork
Are there deadlines for filing medical claims?
Yes. Each medical plan has specific filing deadlines. Many plans require claims to be submitted within 12 months from the date of service.
Submit claims as soon as possible and review your plan documents for exact requirements.
What if my visit was related to a work or auto accident?
Medical claims related to accidents may require coordination with other insurance:
- Work-related injuries in Washington State are typically handled through Labor & Industries (L&I).
- Auto accidents may involve your auto insurance carrier first.
- There may be an incident/accident form mailed to you. This may be required by the Carrier before they will process the claim.
If you are unsure which coverage applies, contact your benefits advisor before submitting the claim.
How long does claim processing take?
Processing times vary by insurance carrier and claim complexity. Once a complete claim is received, many carriers process claims within several weeks.
What happens if my medical claim is denied?
If your claim is denied:
- The insurance carrier will send a written explanation of the decision.
- You have the right to appeal the decision.
Review your Explanation of Benefits (EOB) carefully and follow the appeal instructions provided.
Can Medicare members submit their own claims?
Yes. If a provider does not submit a claim to Medicare and you paid out of pocket, you may file your own claim. If a provider refuses to file when required, contact Medicare directly at 1-800-MEDICARE.
Still Need Help?
Navigating medical claims can feel confusing, especiallywhen something does not process as expected.
Maddock & Associates is here to support you.
If you need assistance understanding a medical claim, submitting documentation, or reviewing a denial, contact our team and we will help guide you through the process.
📧 enrollments@maddockinsurance.com
📞 253-854-0199
