Claims: Everything You Need to Know

What is a health insurance claim? A claim is simply a bill that your doctor or other health care provider will send to a health insurance company (such as Blue Cross and Blue Shield of Texas) for payment after they have treated you.

In most cases, your doctor or other health care provider’s office will submit the claim for you so you don’t have to worry about it. But there are some instances when you may have to file the claim yourself, such as when you get care from an out-of-network provider. Which brings us to the next question: What is a health insurance claim form?

How to Submit a Claim
If you do have to file a claim, here’s what you need to do:

  1. Print out a “Health Insurance Medical Claim Form” from the  Form Finder section in Blue Access for MembersSM
  2. Fill out the form completely. You’ll need to have this information handy:
    1. Date of service/treatment
    2. Type of service
    3. Dollar amount charged by the health care provider
    4. Member ID number (found on your ID card)
  3. Mail the form and the original bill issued by the provider to the address printed at the top of the claim form

It’s a good idea to make copies for your records. The bill you send in with your claim will not be sent back to you.

Also be sure to file your claim soon after you receive care. This is more important when you have a claim from late in the year, to make sure your claim is applied to the right plan year.

Check the Status of a Claim
There are a couple ways you can check the status of your claim:

Please note that the claim will not show up in Blue Access for Members until it is processed. There are 2 types of claims statuses that you will see within Blue Access for Members: “Paid” or “Processed”. “Paid” means we have paid for the services. “Processed” means it is in the works, but no money has been sent out to pay the claim yet.

You can also sign up for text/email alerts to notify you when the status of your claim changes. All you have to do is:

  • Log in to Blue Access for Members
  • Click on Settings at the top of the page
  • Click on Preferences
  • Click the box next to the type of alert you would like to receive under “Alert Preferences”

Explanation of Benefits (EOB) Statement
Once your claim has been processed by us, you will receive an EOB, either by mail or email. This document will break down:

  • The amount billed by your provider
  • Medical benefits that were approved (how much we are paying)
  • Amount you may still owe your provider

If your claim has been denied, you can file an appeal to have it looked at again. The appeals information is located with your EOB.

Still have questions? Ask us in the comments!

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  • ok on the EOB form it also has a 1,2,and 3 explanation of amounts not covered and it say's I will not be billed the difference, or they can not bill me the difference but I am, and when I call you the insurance company and ask if i have to pay it you say yes. And why am I having to pay for preventive screenings, paps smear, mammogram, ect.. i am 45 years old, my mother has had 2 breast removed because of breast cancer, yet I have had to pay for my mammogram. I was wondering why. Thank You Shani Goldsmith.

  • Hi Shani, If you'd like to send us a private message with your plan ID and contact information I can have my team give you a call to answer these questions. ~ Kayla

  • We visited the Drs offive today we went to walgreens to fill the rx but they told me one medicine was not covered. How do i claim this item? Or are not elegible?

  • Hi Salvador, If you'd like to send us a private message I can have my team take a look at what's going on. ~ Kayla

  • Hi , talking about claims there are reasons for claims to be denied. The insurance provider rejects a claim due to various reasons such as having a no covered charge, a referral or pre-authorization because of the usage of an out-of-network provider, minor transcription errors, the acceptance of claim in the wrong insurance company or other information errors. Know more about denial management at fasttrackclaimsinc.com/denialmanagement.html

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