A claim is information your doctors, hospitals, and healthcare service providers send to Humana asking to be paid for their services. The bill has special codes for each service you received and the doctor's normal charge for each service. When Humana gets this bill, it becomes a claim.
Doctor and Hospital billing may seem confusing, but it doesn't have to be complicated. Here are key points to keep in mind when you receive a bill from your doctor or hospital.
1. Bills and Explanation of Benefits (EOB) are not the same. An EOB from Humana is not a bill. It is a summary of how Humana has processed your claim. It will show 1) the total charges for the services you received, 2) how your Humana benefits were applied and 3) what the doctor or hospital will charge you. At the same time, your doctor or hospital will receive an Explanation of Remittance (EOR) with the same information as your EOB. This lets your doctor or hospital know Humana has processed your claim and allows them to adjust your final bill. The bill your doctor or hospital will send you includes the balance due and a date when your payment is due
Hint: Organize and hold on to bills and EOBs in case you need to refer back to them.
2. You could receive multiple bills and EOBs for the same hospital visit. Each visit could involves the collaboration of several doctors and other medical professionals who are not employees of the hospital. In addition to the hospital, all of these doctors could bill you separately.
Hint: Create a file for the bills and EOBs that come from each different care provider such as the cardiologist, radiologist, anesthesiologist or lab technician.
3. You may receive a bill even if you have insurance. Your doctor or hospital may send you a bill before Humana processes your claim. This bill might indicate that you owe the entire amount but It is typical for, doctors and hospitals to send you an updated bill after Humana processes your claim. This updated bill should be based on the amount remaining after Humana has processed your claim. Humana will also send you an EOB indicating how much you are responsible for.
Hint: Know your benefits. Keep a copy of the EOB and compare it to your bills in order to verify accuracy.
Important information about out-of-network emergency services
Your policy includes a group of doctors, hospitals, and clinics called a network. Emergency services provided by doctors and hospitals outside of your network will result in much higher costs to you. The amount that Humana will pay for emergency services under your policy is based upon a number of policy provisions, including Maximum Allowable Fee. The doctor or hospital may send you a bill for the additional amount that you owe. These charges are in addition to your annual deductible or maximum out-of-pocket costs for the year.
4. Humana processes claims in the order that they are received. Claims are not always processed in order by the date services were rendered.
5. Humana may need additional information from your provider. In certain situations, Humana may request medical records or Emergency Room notes in order to complete the processing of your claim. If information is requested from you, your doctor or hospital, you should be notified.