Health Insurance Claims and Benefits
Core concepts
Know the claims process: notice of claim, proof of loss, claim forms, coordination of benefits, and claim payment timelines. Understand allowed amount, usual, customary, and reasonable (UCR) charges, balance billing, and network discounts. Know preauthorization, utilization review, case management, and appeals (internal and external).
Understand benefit structures: scheduled benefits, usual and customary reimbursement, indemnity benefits, and coinsurance/copay application. Know exclusions and limitations, pre-existing condition rules, and waiting periods. Understand subrogation and third-party liability. Recognize the role of EOB (explanation of benefits) and remittance advice.
Traps
Questions often confuse billed charges with allowed amounts, or assume balance billing is always the member's responsibility (network contracts and surprise-billing rules may limit it). Another trap: treating preauthorization as a guarantee of payment. Watch for appeal deadline questions and for coordination-of-benefits order rules.
Worked example
A provider bills $1,200. The insurer's allowed amount is $900, and the member has a $500 deductible and 20% coinsurance. The member pays $500 deductible plus 20% of the remaining $400 = $80, for $580. The insurer pays $320. The provider may not balance-bill the $300 difference if it is in network.
Rule of thumb: Claims pay the allowed amount, not the billed charge; cost-sharing applies to the allowed amount.