Dealing with Virginia Health Insurance Claims

Things to do before you file a claim:

• Review your policy, employee handbook, benefit booklet or EOC carefully to be sure the service in question is covered.
• Follow any rules, including pre-certification requirements and use of network providers, if applicable.
• Find out if your provider submits the claim for you or if you need to do it.

How to submit a claim properly:

• If you need to submit a claim, review the information to be sure it is complete and correct.
• Include your policy number and other identifying information.
• Submit the claim promptly following the accident or illness.
• Send the claim to the right address.
• Keep copies of all documentation for future reference.

Allow reasonable time for the company to process the claim. The company should inform you if it needs any additional information to complete the claim.

If your claim is paid:

• If you assigned benefits to the provider, the payment will go directly to the provider. You will pay any deductibles, co-insurance or other cost-sharing amounts.
• If you did not assign benefits, the payment will go directly to you, and you will need to pay your providers for the entire amount due them.

If your claim is denied:

• The reason for denial should be stated on your explanation of benefits.
• If you disagree with the reason for denial, review the policy, EOC, employee booklet or benefit booklet for information on review of the claims decision.
• The company should answer any questions you may have.
• If you cannot get the problem resolved by dealing directly with the company, the Bureau of Insurance will assist you with claims and complaints.