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2 days ago
EBTEHAL BAAWADH
Health Insurance Claim.
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A health insurance claim is a request made by a policyholder or healthcare provider to an insurance company for payment of health services. The insurance company’s claims-processing system reviews the request to determine if the provided service or treatment falls within the coverage of the insurance policy. Once verified, the healthcare provider receives the appropriate payment (Adzakpah & Dwomoh, 2023).
A situation that would trigger a medical insurance claim is when an individual seeks medical treatment or services covered by their insurance policy such as visiting a hospital for surgical treatment.
The path taken to resolve the insurance claim typically involves the following steps (CHIC, n.d.).:
1. Medical Treatment: The individual receives the necessary medical treatment for their condition, such as surgery in this case. It is important to ensure that the treatment is within the coverage of their insurance policy.
2. Documentation: The healthcare providers generate and gather all the relevant documents, including medical records, bills, and receipts related to the treatment.
3. Claim Submission: The individual or the healthcare provider submits the insurance claim to the insurance company. This can often be done electronically through online portals or by mailing the necessary documents.
4. Claim Processing: The insurance company reviews the claim, verifies the details, and determines its eligibility for coverage based on the policy terms and conditions. They may also request additional information or clarification from the healthcare provider.
5. Adjudication: The insurance company evaluates the claim for reimbursement and calculates the amount to be paid based on the applicable coverage and any deductibles, co-pays, or coinsurance amounts specified in the policy.
6. Claim Resolution: Once the claim is processed and approved, the insurance company issues payment to the healthcare provider directly or reimburses the insured individual, depending on the policy terms.
It is important for the insured person to carefully review their insurance policy to understand the specific time limits and requirements for claims resolution. It is also advisable to keep copies of all submitted documents and correspondence with the insurance company for reference and future inquiries. Overall, timely notification, accurate documentation, and adherence to the specific time limits mentioned in the policy are vital in resolving insurance claims efficiently.
According to (Adzakpah & Dwomoh, 2023) Digital Health Technology (DHT) recorded lower denied claims costs than the paper-based claims system. Scaling up the use of DHT for claims submission will reduce the rate of claim denials and ensure the sustainability of providing healthcare services.
References
Adzakpah, G., & Dwomoh, D. (2023). Impact of digital health technology on health insurance claims rejection rate in Ghana: a quasi-experimental study. BMC Digital Health, 1(1). https://doi.org/10.1186/s44247-023-00006-3
Cooperative Health Insurance Council (CHIC). (n.d.). Regulation of Qualification of Health Insurance Claims Management Companies. Retrieved October 19, 2023, from https://chi.gov.sa/en/Rules/Pages/list2.aspx
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