Health insurance claims can often take time to process, leaving policyholders wondering when they can expect to receive reimbursement. The time it takes for an insurer to pay a claim depends on several factors, including the complexity of the claim, the accuracy and completeness of the submitted paperwork, and the internal procedures of the insurance company.
While it’s normal to feel anxious awaiting claim payment, familiarizing yourself with timeframes defined in laws and regulations can provide peace of mind. This article outlines guidelines dictating claim payment deadlines, provides tips to expedite the settlement process, and explains steps to take if a health insurance company is tardy in reimbursing you.
Claim Processing Timeframes Defined in Law
Laws like the Affordable Care Act established prompt payment regulations to prevent insurers from delaying valid claims. These rules vary slightly depending on whether you have individual health coverage or an employer-based group plan.
Individual Policy Claims
For individual policies purchased on or off the ACA’s health insurance marketplace, insurers must pay or deny clean electronic claims within 30 calendar days of receipt. Paper claims get a little more time – 45 calendar days from receipt.
If an insurer needs additional information to process the claim, it must notify you within 30 days for electronic submissions and 45 days for paper claims. Once the insurer obtains the requested information, it has another 15 days to make a determination.
Employer-Based Plan Claims
The rules are similar but slightly more relaxed for employer plans governed by ERISA (the Employee Retirement Income Security Act). For these plans, claims must be paid or denied within:
- 30 calendar days for electronic submissions
- 45 calendar days for paper claims
As with individual plans, the insurer has an additional 15 days if more information is needed to make a decision.
Factors That Impact Claim Processing Times
While regulations set limits on claim payment times, several factors may cause an insurance company to use the maximum time allotted or request an extension.
Health insurance claims vary greatly in complexity, from routine doctor visits and prescription refills to extensive hospital stays with multiple specialists and procedures. More complicated claims naturally take longer to review.
Paperwork Accuracy and Completeness
Incomplete or erroneous paperwork is one of the biggest reasons claims get delayed. Double check that you’ve provided all required information before submitting a claim.
Common paperwork problems include missing procedure or diagnosis codes, inaccurate policyholder information like an incorrect birthdate, and neglecting to submit referrals or pre-authorizations when required by the insurer.
Provider Network Status
Insurers process claims faster when the care provider is in-network versus out-of-network. Verifying network status for all providers seen will avoid surprises and claim hold ups.
An insurance company may struggle to meet prompt payment deadlines during busy seasons when claim volume is unusually high. Enrollment periods for marketplace plans and renewal for group health plans often create temporary backlogs.
Investigations for Fraud
If something about your claim raises suspicions of fraud, the review process slows significantly while the insurer investigates. Some warning signs include billing for services not performed, charges that seem excessive, and claims that don’t match the diagnosis.
Appeals and Requests for More Information
Should the insurance company initially deny your claim, appealing the decision restarts the clock. The appeal must now be reviewed within the standard claim determination timeframes.
Requests for additional information also hit pause on the timeline until the insurer receives what was asked for.
Tips for Faster Health Insurance Claim Processing
You can avoid unnecessary delays and get your claims paid faster by taking the following steps:
Go In-Network: See providers who participate in your insurer’s network whenever possible. Out-of-network claims take longer.
Check Claim Status Online: Logging in to your insurer’s website lets you see outstanding claims and follow up on any issues immediately.
Correct Errors Quickly: If your claim gets rejected due to incomplete or wrong information, resubmit it with the right details ASAP.
Provide Details Upfront: Don’t wait for your insurer to request information. Attach relevant medical records, itemized bills, and explanation of benefits statements from other insurers to facilitate review.
Follow Up on Pending Claims: Don’t hesitate to call your insurer if a claim is approaching or exceeds the legal time limit without a determination.
Go Electronic: Submit claims electronically rather than on paper. Electronic claims get paid several weeks faster.
Review Before Submitting: Carefully double check your claim for accuracy and completeness before sending to avoid paperwork-related delays.
Steps to Take if Your Health Insurer is Late Paying a Claim
Despite your best efforts, you may find yourself in a situation where your health insurer fails to reimburse you within the legally defined timeframes. If this occurs, grip the following steps:
Contact your insurer to check on the claim status. There may be an easily resolved issue holding up payment.
File an Appeal
For denied claims that you feel should have been paid, go through your insurer’s appeal process. Include new information supporting your case for reimbursement.
Submit a Complaint
If contacting your insurer fails to resolve the issue, file a complaint with your state’s department of insurance. They can intervene when prompt payment rules are violated.
Consult Legal Counsel
As a last resort if other steps are unsuccessful, talk to a lawyer about legal remedies. A letter from an attorney often gets an insurer’s attention.
The Bottom Line
Understanding prompt payment laws helps set realistic expectations for when your health insurance claims will be paid. While most claims process without excessive delays, being proactive improves your chances of faster reimbursement. Reach out for help if an insurer frequently drags its feet settling claims.
Health insurance can seem complicated when it comes to claim reimbursement timeframes. Legal regulations created to protect consumers set maximum limits for insurers to follow, but claim and paperwork accuracy play a big role in avoiding delays. With a combination of diligent record-keeping, staying in-network, monitoring claim status online, and following up promptly on any payment lags, you can optimize how quickly your health insurer settles claims.
Q1: How long does health insurance typically take to process and pay a claim?
Health insurance claims are usually processed within 30 to 45 days after they are submitted. The actual time can vary depending on the complexity of the claim and the insurance company’s policies.
Q2: What factors can cause a delay in the processing of a health insurance claim?
Delays in processing health insurance claims can occur due to missing or incomplete documentation, disputes over coverage, coordination of benefits with other insurance plans, or the need for further investigation into the claim’s legitimacy.
Q3: Is there a legal timeframe within which health insurance must pay a claim?
While there is no specific federal law that mandates a timeframe for health insurance claim payments, many states have regulations in place. These state laws often require insurance companies to process and pay claims within a certain number of days, typically ranging from 15 to 45 days.
Q4: Can I check the status of my health insurance claim online?
Yes, most insurance companies provide online portals or apps where you can track the status of your health insurance claim. You can log in to your account, view the progress, and even get an estimated payment date.
Q5: What should I do if my health insurance claim is taking longer than expected to process?
If the expected timeframe delays your health insurance claim, you should contact your insurance company’s customer service department. They can provide you with an update on the status of your claim and address any issues that may be causing the delay.