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Who Pays My Insurance Claim & How Is it Sent?

Insurance companies usually handle the processing and payment of claims. Though they may contract with another party to handle this administration, typically, the insurer employs staff to process and pay claims. How the claim is submitted, i.e., by paper claim form or electronically, will decide how much manual intervention is necessary. In addition, depending on the provider, network status may direct who submits and pays the claim.

  1. Claims Payor

    • In most cases your insurance company pays claims. Occasionally an insurance company may contract with a third-party administrator to process claims and payments. A insurer may also "carve out" the program administration, management and claims payment for services such as behavioral healthcare. But your insurance company usually handles all aspects of claim processing. If you are unsure where to submit a claim, call the number on the back of your ID card.

    Paper Submission

    • Paper claim forms are used, though the trend is toward electronic submission. These may need to be submitted on a CMS 1500 form (for outpatient services) or a UB-04 form (for inpatient services) or an insurer-specific form. Ask your insurer what type of claim form it will accept. Paper claim forms are used when you need reimbursement for payments made out-of-pocket or by small-provider offices that may be out-of-network or not as technologically savvy as larger offices.

    Electronic Submission

    • Large insurers accept many claims electronically. Doctors' offices, hospitals, labs and other larger providers send an electronic file to the insurer for immediate processing of claims. Not only is this method quicker than paper claims, the process is automated on the insurer's end, leading to less data-entry errors and quicker turnaround times for payments. The insurer will work with providers wanting to set up the electronic claims submission by providing guidelines on what software and transmission methods are acceptable.

    Provider Network Status and Claims

    • Though your provider handles most claims submission, you may need to submit some claims. If you seek care from a non-participating provider, you will be responsible for submitting claims for reimbursement and paying your provider. Some providers may require payment at the time of service, or will send you an invoice instead of submitting a claim to your insurer. Network providers sign an agreement by which they are responsible for submitting claims and cannot bill the patient for the difference between the claimed amount and the what they were actually paid.

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