• Aetna
• Assurant
• Blue Cross and Blue Shield

Click for more options

• GoldenRule
• Humana

• Supplemental Medigap Insurance
• Medicare Advantage Insurance
• Blue Cross and Blue Shield

Click for more options

• CIGNA
• SecureHorizons by UnitedHealthcare
• Unicare
• Universal American
• WellCare

North Carolina Health Insurance Claims & Pre-Certification

Before You Receive Health Care Services

Plan Ahead

Read your policy or employee benefits booklet carefully to be sure what services are covered. Follow any managed care rules, such as the use of network providers. Give correct insurance information to your provider. If you, your spouse or your covered dependents have health care coverage under more than one group plan, you should review each employee benefit booklet to determine which policy is primary and which is secondary.

Pre-Certification

Many plans require you to contact the insurance company for approval before you check into the hospital, have elective surgery, visit specialists or have expensive tests. The steps should be spelled out in your policy benefits booklet. Pre-certification does not necessarily guarantee the payment of your claims. However, if your plan pre-certifies a service, it cannot later deny coverage on the grounds that the service was not medically necessary, unless the pre-certification was granted based on false information from you or your provider. Please note: An insurance company cannot require pre-certification for emergency medical services or treatment.

Filing Claims

Submit Claims Properly

Find out if you are responsible for filing your claims or if your provider will file them for you. If you are required to submit the claim, review the information to be sure it is complete and correct before forwarding it to the insurance company. File it as soon as you receive the bill from the provider. Send it to the correct address and keep a copy for your records.

Allow a Reasonable Time

For many types of health insurance plans, the insurance company must take action on a claim within 30 days after receipt. "Taking action" means the insurance company must pay, deny, or pend the claim for additional information. If the insurance company requires additional information, it must specify what is needed. After receiving the additional information, the company has an additional 30 days to take action on the claim.

Explanation of Benefits (EOB)

The Explanation of Benefits (EOB) is a statement sent to you from the insurance company, explaining its claim determination and benefit calculation. Information provided on the EOB should be carefully analyzed in conjunction with your medical bills and policy contract. Any questions or discrepancies should be promptly addressed with the insurance company.