How to Talk With Your Health Insurance Company

The Basics

1. When you call your insurance company, write down the first name and last initial of the person who helps you. Sometimes the customer service person will give you a telephone extension or confirmation number. Write it all down. This will make it easier if The Medical Center’s billing office later needs to speak to your insurance company about one of your claims.

2. If the customer service person gives you conflicting or unclear information, ask him or her to repeat the information from the beginning and to explain any unfamiliar terms or abbreviations. Ask them to wait if you need extra time to process what they are telling you. If you disagree with what the customer service person tells you, be sure to ask him or her to consult with a team member or a supervisor.

Questions to Ask Your Insurance Company About Your Policy

(Terms in red appear in our glossary of terms)

1. Find out if you have a yearly deductible and how much it is. Does it apply to all visits, procedures, and tests?

2. Find out your percentage of co-insurance, if there is one.

3. Ask about your co-pay for the following: emergency room visit, doctor’s office visit, or visit to a specialist. Whenever possible, be prepared to make your co-payment at the time you receive services.

4. Ask if the insurance company will send you an “explanation of benefits” (EOB) each time a claim is filed? If not, you can request that one be sent routinely.

5. When asking about what you will have to pay, find out about your deductible, co-insurance, and a co-pay as it applies to the service or procedure in question. Finally, ask: Will I end up with a bill?

Glossary of Terms

Deductible: A set dollar amount you pay for medical services per year before your insurance company begins making payments for your covered medical expenses. You may have an individual or a family deductible. Some plans have separate deductibles for different services.

Co-Pay: A fixed dollar amount that you are expected to pay for certain medical services at the time you receive those services. For example, you may have a $15 co-pay for each doctor’s office visit and your insurer may cover the rest of the cost. There may be different co-pays for different services.

Co-Insurance: You may be responsible for a set percentage of your medical expenses, after you’ve met your deductible. For example, some plans require you to pay 20% of covered medical expenses, with the insurance company paying the remaining 80%.

Explanation of Benefits: Once your insurance company processes a claim, it may send you a detailed summary of your covered benefit for that service, procedure, or test. If you do not receive an explanation of benefits, you may request one from your insurer.