How the Claims Process Works
Navigating the claims process can feel overwhelming, but at HSR, we’re here to make it simple. Whether you’re filing your first claim or looking for guidance on next steps, we’ve got you covered. Below is a step-by-step guide to help you through the process, with clear instructions and helpful resources along the way.
To get started, you’ll need to fill out and submit a claim form. This can be done by either you, the claimant, or the policyholder (which might be your school district, daycare, employer, etc.). The form will need a signature from the policyholder.
Once we’ve received your form, we’ll send you a confirmation letter and instructions for the next steps—don’t worry, we’ll guide you through it.
After sending in your claim form, the next step is gathering any supporting documents like itemized bills and an Explanation of Benefits (EOB). Keep in mind that it might take a month or more to receive these from your healthcare provider, and you may need to ask for an itemized bill yourself.
Important: A balance due statement won’t work as supporting documentation. You’ll need an itemized bill that shows the detailed charges.
Want to see what these forms look like? See examples below.
Ways to submit your documentation:
- Fax
- Upload via our website
You don’t need to use the same method for submitting your claim form and supporting documents—choose whatever works best for you, and we’ll take care of the rest.
Sample UB04 Billing
Sample CMS HCFA Billing
Once we’ve got all the right documents, we’ll process your claim. This usually takes about 7-15 business days. If we need more information or have any questions, we’ll be in touch to keep things moving smoothly.
An Explanation of Benefits (EOB) shows how your primary insurance processed the claim for the care you received. It explains:
1. The services provided
2. The doctor or hospital’s charges
3. What your insurance covered and didn’t cover
4. What your insurance paid
5. What you’re responsible for paying
Usually, you’ll get your EOB within 30-60 days after receiving care.
An EOB includes specific information necessary for the processing of your excess medical claim including the following:
Account Summary: Your personal details, member ID, claim number, and insurance group number
Claim Details: The services you received, provider’s name, location, date, and any applicable reference numbers or medical codes
Amounts:
1. The charges from the provider
2. What your insurance agreed to pay
3. What you’re responsible for paying
An itemized bill is a detailed list of all the charges from your provider, showing exactly what you or your insurance are being billed for. All billings must include the provider’s name, address, tax identification number, diagnosis code, date of service, procedure code and the billed amount. These are commonly shown on a HCFA or UB-04 Form (see examples above in Step 2).
A balance due statement doesn’t show enough detail to process your claim. We need an itemized bill that lists each charge, which usually comes in the form of a CMS HCFA-1500 for doctor services or a UB04 for facility charges.
If you have any questions or need assistance at any point, our support team is just a phone call or email away. We’re here to help you navigate the claims process smoothly.