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Ask The Insurance Decoder

Lynne Lucio

By Lynne Lucio

Q. My insurance company plan requires a deductible on out-of-network providers.  How does my insurance company know when I’ve met my deductible if I’m paying my out-of-network providers at the time of service?—John S., Los Angeles, CA

A. This is a question that confuses many people.  First of all, your insurance company does not know when you’ve paid any portion of a claim unless someone (either you or your provider) lets them know.  When using the services of an out-of-network provider, and you pay your provider, ask them for an itemized claim.  For doctors and other ancillary providers, these claim forms are called 1500s although some still refer to them as HCFAs.  If you’re the dependent of a covered employee, make sure the employee’s social security number is on the claim.  This is required because all claims for a family are organized under the employee’s social security number in the insurance company’s system.  Once you have the itemized claim form, send a copy to the insurance company.  They will process it through their system and send you, and your provider, an explanation of benefits that lists all of the charges and the amount of deductible you are responsible for.  Keep in mind, that if you’ve already paid the provider, you’re not required to pay it again.  By sending the insurance company the claim, they can keep a running tab on the deductible.  This way, their system knows when you’ve met the annual deductible.  Once the deductible is satisfied, the insurance company will start paying their portion of claims in that plan year.  The whole process starts over at the beginning of a new plan year.  For plans that have an in-network deductible, generally the in-network providers will submit the claims directly to the insurance company for you.

ASK The Insurance Decoder © Copyright 2012, Lynne Lucio.  All rights reserved.

Lynne Lucio, the author of The Insurance Decoder:  How to Maximize Your Health Insurance Benefits, Minimize Out-Of-Pocket Expenses and Stay One step Ahead of Your Insurance Company, has been a health insurance professional for over 20 years.  As an insurance insider, Lynne learned how to decipher the medical claims labyrinth and developed the specific and practical knowledge of the claims process.  Throughout her career, Lynne has shared her expertise with thousands of insured consumers, helping them resolve complicated health claims while showing them how to take full advantage of their health insurance benefits.  The depth and breadth of Lynne’s knowledge of the topic encompasses not only the claims process but also the laws that influence and regulate health coverage, including ERISA, COBRA, FMLA, USERRA, HIPAA and others.  Lynne provides consulting services to covered individuals and writes about health insurance issues on (

For more information, or to submit your own health insurance related questions, contact Lynne at

  Your question may be answered in a future column.

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