Providers, facilities and vendors who provide you with medical services submit their bill, also known as a “claim”, to either Hill Physicians or your health plan for appropriate processing. You are generally not responsible for a claim submitted by an in-network provider, however, each health plan is different.
How the Claim Process Works
After a claim is submitted, it can either be paid, rejected or denied.
The provider submits a claim for processing to determine your benefits. Based on Hill Physicians’ agreement with your health plan, services may be paid by Hill Physicians or directed to the health plan for payment. If another health plan is involved, the health plans coordinate benefits to determine which plan is responsible for the charges.
The health plan generates an Explanation of Benefits (EOB) for claims they pay and/or Hill Physician’s pays and sends the EOB to you and your provider. This document is not a bill, though it may look like one. It explains what was covered by your insurance.
A rejected claim is one that fails to meet specific criteria and data requirements that are rejected by health plans. Once the errors are corrected, a rejected claim can be resubmitted. These errors can be as simple as an inaccurate ID number/name and can usually be rectified quickly.
A denied claim is one that is processed by the health plan and/or Hill Physicians with no payment made. A denied claim cannot simply be resubmitted. It must be determined why the claim was denied. Having that information available allows an appropriate appeal to be written or a reconsideration requested from the provider.
Timely Submission of Claims
Claims must be submitted within 365 days of the date the services were rendered. Claims submitted for dates of service 365 days or older will be denied with the reason “Time Limit for Submission Exceeded”.
Other Health Plan Benefit Documents
For details about your coverage, all health plan members should review their Disclosure Form and Evidence of Coverage. These documents are required by the Department of Managed Healthcare (DMHC) and the Centers for Medicare and Medicaid Services (CMS). Health plans are required to provide these documents to members, on demand, when requested. Reviewing your health plan benefit packages are the best way to understand what you are responsible for when it comes to claims and payments.
These documents also contain details on Grievance and Appeals processes. In brief, health plan members have the right to file an appeal for any bill or claim they have received. Members should contact their health plan to question any claim or file an appeal for processing.
Help With Claims
If you are a Hill Physicians member, we can help you track down the details of your claim. While we recommend contacting your health plan for benefit package details, we have the ability to research any claims which your providers have submitted to Hill Physicians.