Submitting Insurance Claims

If a doctor doesn't submit the claim to the carrier automatically (such as out-of-network providers), here is how a claim can be submitted manually to the carrier for reimbursement.

Medical Claim and Prescription Reimbursement Forms

There are generally two types of claim forms: a medical claim form, or a prescription drug reimbursement form. Here's a quick comparison: Medical Claim Form A medical claim fo... Learn more

Preauthorization and Procedure Codes

Any time someone receives a service from a provider, the service(s) rendered are tied to established Procedure Codes. These codes are used to tell the insurance carrier wha... Learn more

Submitting a Claim Manually

Here are some tips on manually submitting claim forms to a carrier: Finding The Right Form Determine whether a Medical Claim Form or a Prescription Drug Reimbursement For... Learn more

Disputing a Claim

Subscribers can dispute claims if they believe their carrier has processed a claim incorrectly according the plan's Explanation of Benefits (EOB). The carrier will review the di... Learn more

Explanation of Benefits (EOB)

The Explanation of Benefits (EOB) is a document sent by carriers to provide details on how a claim was processed. Even if the carrier didn't pay anything for the service, subscr... Learn more

Allowable Amount for Insurance Claims

The allowable amount (also referred to as allowable charge, approved charge, eligible expense) is the dollar amount that is typically considered payment-in-full by an insurance ... Learn more

Balance Billing for Insurance Claims

In balance billing, the provider bills a subscriber for the difference between the provider’s charge and the allowable amount. For example, if the provider’s charge is $100 ... Learn more

Submitting Claims With Private Exchanges

Employees enrolled in an insurance plan through a private exchange, such as CalChoice, should not submit claims directly to the exchange. Instead, claims should be submitted... Learn more

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