How Long Does It Take Health Insurers To Process a Claim?

You’ve gone to the doctor, done lab work, needed X-rays, or a specialty procedure. You pay your copay if you have one, and then you go home. Weeks or even months later, you receive an Explanation of Benefits (EOB) letter in the mail from your insurance company. This document shows the medical treatments you had and which of those services were paid to your doctor by your insurance. It also shows which services your insurance didn’t cover and what costs you’re now expected to pay to your doctor.

Then you start to ask questions. Why didn’t the doctor know about these extra fees at the time of your appointment? Why has it taken this long for you to get this statement? Why didn’t your insurance cover everything?

These are all important questions, but the one we’ll answer in this post is how long it usually takes health insurance companies to process your claim.

How Does the Claims Process Work?

When you require medical services, you have your appointment and when you leave, the doctor’s office often tells you they’ll bill your insurance. Sometimes, you pay a copay either before or after your visit, and you go on your merry way. Here’s some insight into how the medical claims process usually works:

1. After you visit your doctor or other health-care professional, the doctor sends a bill to your insurance company for any charges you didn’t pay at the time of service.
2. A claims processor with your health insurance company will then check the claim for accuracy and whether the service you received is covered under your plan.
3. If the service is covered under your plan, the insurance company pays the claim.
4. You receive an Explanation of Benefits (EOB) in the mail sometime later, which outlines the services you had and what was and wasn’t covered by your plan.

Sometimes, the insurance company covers the entire cost, and others only cover a portion, depending on your benefits, and you’re responsible for paying any remaining portion. You’ll get an EOB letter from your insurance, which is NOT a bill but a breakdown of services and coverage. If there are remaining costs that your insurance doesn’t cover, you’ll receive a bill from your doctor.

How Long You Have To Wait

So, how long does the insurance claims process take?

Unfortunately, there’s no quick and easy answer.

Most insurance companies pay a claim within 45 days of your doctor sending it to them. If the insurance doesn’t pay a claim within that timeframe, the doctor may request that you contact your insurance directly and ask them to process the claim.

They also explain that you may not receive a final bill from your insurance company for 3 to 12 weeks, depending on how quickly your insurance company can complete the claims process.

Additionally, per Nevada health insurance statutes, all insurance companies (the payer) are required to do the following:

• Establish a tracking system to monitor the timeliness of the payer’s processing of the claim
• Maintain a written or electronic record of the date the claim is received
• Provide receipt of a claim within 20 working days

A claim is deemed received by a payer either five working days after the date that the health-care provider or medical facility placed the claim if the provider has the receipt of mailing the claim, or on the date the receipt of the claim is recorded by courier if a courier was used.

What’s the Claims Process Consensus?

As you can see, the simple answer to how long an insurance claim takes to process is that we’re not sure.

If you call your insurance provider, they’ll likely give you a general time frame, such as what Dignity Health mentions on their website. And, even with Nevada state laws in place requiring insurance companies to track your claim and provide proof that they received it, those companies don’t seem to have a required time frame to complete the processing of your claim.

We know that waiting to find out if your medical procedure is covered under your insurance plan and dreading the possible dollar amount on that final bill is not a fun place to be in. The not-knowing is frustrating, and when your claim is finally processed, and you get that bill, often it’s much higher than you were originally quoted by your doctor, which only adds another level of stress.

If you have questions about health insurance claims you’re waiting on, or you believe that your insurance wrongfully denied a claim from your doctor, you have legal recourse available. The Law Office of Matthew L. Sharp offers free case evaluation to Nevada residents, and we won’t charge you a fee unless we win your case. So, reach out to us today and see how we can help you! Health care and insurance companies can be complicated, but dealing with these issues that arise doesn’t have to be.