The medical billing and insurance claims process begins when you go to a medical provider or facility outside of the W&M Student Health Center (SHC) to access healthcare services. Most of the time, this process works smoothly, but it is the insured student's responsibility to ensure that the claims process works like it should so there are not delayed or denied claims with large out-of-pocket medical expenses for you.
Before your visit
- It is important to accurately and completely fill out those new patient forms so that the provider can effectively treat you, their billing office can submit the medical bill/claim to your health insurance for consideration and so that there are no unnecessarily delayed or denied medical claims.
- Know your policy provisions and obtain any SHC Referral Required BEFORE you incur expenses for medical treatment rendered outside the Student Health Center (SHC). There are certain circumstances or conditions in which a SHC Referral is not required. Review the Student Health Center (SHC) Referral Required policy provision (also in the plan certificate) so you know whether or not a Referral is required.
- Please note that a Specialist Physician may still require that you obtain a referral from the SHC, as your Primary Care Provider (PCP), before they will see you because they need information about why you have been referred to their office for diagnosis or treatment.
During your visit
- The healthcare provider and their staff will record and assign the appropriate medical coding to summarize their professional services. The CPT (Current Procedural Terminology) codes are used for the various diagnostic/therapeutic services and the ICD (International Classification of Disease) codes are used to designate the symptoms or diagnosed condition.
- A summary of your demographic data (full name, date of birth, mailing address, etc.) and a summary of services, communicated through these code sets make up the healthcare provider's bill/claim that they will send directly to the Insurance Company.
- You may be expected to pay your applicable copayment ($25 for office visit), policy deductible ($150, if not already met), and coinsurance (20% after deductible) at the time of your appointment.
- Usually the provider prepares and submits the medical bill/claim to the Insurance Company electronically, but occasionally the bill/claim is prepared manually and sent by mail. Some medical services may involve multiple healthcare providers or facilities such as when you are seen in the Emergency Department of a hospital or when diagnostic imaging is ordered, when anesthesia is administered before or during surgical procedures or when biological tissue is sent to a pathological laboratory for examination. When this happens, EACH provider will bill separately for their professional services. These ancillary providers usually obtain the necessary information for medical billing from the original healthcare provider's registration material.
- Healthcare providers must submit medical bills/claims to UnitedHealthcare StudentResources, the Student Insurance Company within 90 days of the date of service. The provider's office may or may not send you a billing statement while they are awaiting a response from your Insurance Company. Always open your healthcare bills and take action in a timely manner to avoid any late fees or negative action on your personal credit report. Review Common Mistakes if your receive a bill from the healthcare provider that doesn't appear correct.
After your visit
- The bill/claim is received by the UnitedHealthcare StudentResources (UHCSR) Plan Administration office in Dallas TX and then it is routed to the appropriate staff member for processing. It may take 30-60 days for a claim to be completed, but with electronic claims it can be as quick as 14 business days.
- The healthcare bill is evaluated by the electronic claims system or a claims examiner to determine if the medical expense and/or condition is covered under the Student Insurance Plan. If UHCSR requires more information to be able to determine if the claim is payable under the policy, then UHCSR will submit a request for additional information directly to the healthcare provider or will send a electronic message to the insured student. It is important that either you or the healthcare provider reply in a timely manner to these request for additional information or the claim must be denied after 2 attempts to obtain the additional information.
- If UHCSR has all the information needed to complete the claim they will do so and then send to both the insured student and the healthcare provider an Explanation of Benefits (EOB) statement by electronic notification or by mail. The healthcare provider will also receive any insurance benefit payment due to them in accordance with the W&M Student Insurance Policy at that time.
- The healthcare provider will receive their EOB statement and insurance payment and they will post the appropriate credits to your account and then they will send to you a billing statement for the balance that is determined to be the patient's responsibility. You should verify that the balance billed to you takes into account all amounts paid, Preferred Provider discounts and adjustments determined by the Insurance Company. Once you have verified that the amount due on the provider's billing statement is correct, then you should pay the amount due directly to the healthcare provider or contact them to make payment arrangements if you are unable to pay the full amount due.