up button arrow
https://texasinsurance.org is a privately owned website that is not owned or operated by any government agency

ACA Health Insurance Claims in Texas

In Texas, an ACA insurance claim is a payment application submitted by you or your healthcare provider to your ACA insurer when you receive items or services covered by your plan. To file an ACA health insurance claim, you notify your insurer about the medical services you received and all the information about them. Your insurer provides you with a claim form to fill and submit. When a claim is filed, the insurer reviews the information and, if approved, pays for the service. If the claim is denied, the insurance company does not pay. If your claim is denied, you may be able to appeal the decision.

How Do I File a Claim in ACA Insurance?

In most cases you do not have to file ACA claims by yourself, because the medical facility you have visited does this for you.

In case you must report a loss for ACA-compliant insurance in person, you need to contact your insurance provider about the medical services or treatment you or anyone covered by your plan received.

If you need help, you can always reach out to the health insurance agent who advised you to purchase the plan, for further guidance. They are your link to the insurer and are there to help you out.

Once the insurer is aware of your need to file a claim, you will be required to fill out a claim form with information about:

  • You (the policyowner)
  • Your health insurance ID number
  • The person who received treatment or service
  • The treatment or service received
  • Receipts or documents that serve as proof of the treatment or service and its cost

Try not to make mistakes with spelling or important information like dates and prices. Your insurer will review all the information and decide if your claim should be paid. The ACA insurer's review is based on the terms of your policy and the history of your claims.

Preparing a loss report may be a time-consuming process, and it can be even more stressful if you are unfamiliar with your ACA insurance coverage. Speak with your insurer's representative or a Texas-licensed insurance agent who can assist you with filing a claim.

Is a Claim a Bill in ACA Insurance?

Yes, the ACA claim is a bill. In Texas, a health insurance claim is a bill for medical services that you or your healthcare provider files for payment to your insurance carrier. After receiving medical services, the healthcare provider sends your insurer a bill (also known as a claim). A claim is a document that lists the services that you received. The insurance company uses the information in the claim to reimburse your doctor for those services.

How Much of the Provider's Bill Does ACA Insurance Cover?

Once a medical provider submits the claim to your insurer, the insurer analyzes the claim, pays its portion and sends you a letter with an Explanation of Benefits (EOB) in the mail. The EOB shows what was billed by the provider, how much it cost,how much of that was covered, and how much is left for you to pay.

If you receive a bill from a provider, you need to check what services are described. If you have recently received an EOB - check to see if this bill has already been paid. If not, contact your insurer or your health insurance agent for assistance with the bill.

Participating providers (those in the network covered by your ACA plan) may bill you only for services that are not covered by your plan, or to collect your portion of the deductible, coinsurance, or copay.

Non-participating providers (those outside of your plan's network) may bill for the difference in their price and the coverage provided by your plan.

Note: All Texas state-regulated plans are protected from surprise billing, also known as back-billing. You can check if your plan is part of the protected group by looking at your ACA health insurance plan ID card. If your ACA plan is regulated by the Texas Department of Insurance (TDI), the card shows one of two codes: TDI or DOI.

To further understand how the ACA insurance bill is covered, we must understand all the costs possibly involved:

Deductible, Copay, and Coinsurance on ACA Insurance Bill

The deductible is the dollar amount of the covered service that must be paid annually by the insured out-of-pocket, before the plan starts paying the main benefit. ACA deductible in Texas can range $0-8,700.

A co-pay, on the other hand, is a fixed dollar amount that you may pay prior to receiving some covered services. ACA copay usually applies to visits of doctors, specialists, and to prescriptions. Co-pay is typically $20-100 and usually does not count towards the annual deductible amount.

Coinsurance is the amount of the billed costs that you are responsible for, after your ACA health plans pays the provider. The split of costs is determined by the type of the ACA plan.

In ACA health insurance, deductible, copay, and coinsurance are all counted towards the annual maximum out-of-pocket amount (MOOP). MOOP is your maximum annual exposure for health insurance, in addition to the monthly premiums.

Coordination of Benefits in ACA Health Insurance

Coordination of Benefits (COB) means that you are covered by more than one health insurance plan at the same time. If a claim is filed, one of the policies is determined as the primary and pays the benefits first. The secondary policy covers the remaining cost, lowering your out-of-pocket expenses. One or more overlapping policies may be ACA-compliant.

How Long Do I Have to File an ACA Health Insurance Claim in Texas?

Insurers typically expect the claim to be submitted no more than 90 days after the date of service, but most Texas ACA health claims are filed by the provider and then processed and paid by the insurer within 30 days from the date of service. The insured is usually not involved in the process.

If you happen to have an old bill from a provider, which for some reason was not filed on time, the insurer will help you, as long as the claim is valid and for services covered under your policy, on the date when the policy was in effect.

However, most insurers usually draw the line at a year and a half from the date of the covered service. If you try to file the forgotten claim after 18 months, the insurer may deny the claim. Make sure to read your specific policy for your insurer's outlined timelines..

What Happens After I File a Claim With My ACA Insurance in Texas?

After you file an ACA health insurance claim, the insurer reviews all the information you presented along with the terms of your policy. The result of the review may be an approval or a denial of your claim. If the claim is approved, the bill gets settled. The settlement can be in the form of reimbursement or cashless benefits. The amount you get in settlement is usually dependent on the claim. If you have an issue with how much the insurer covered, you can submit a complaint to the Texas Department of Insurance or the health insurance Marketplace.

If they deny your claim, you can appeal their decision. Your ACA insurer is required by law to provide you with the reason why your request was denied. It is the reason provided that becomes your grounds of appeal.

How Do ACA Health Insurance Companies Pay Out Claims in Texas?

If the ACA claim is approved, the payment can be in the form of cashless benefits or reimbursement. A cashless benefits claim is when you can request that your insurer pays you by covering medical expenses when you use the services of their network health professionals. Thus, instead of paying your deductible or an out-of-pocket payment, your insurer covers the expenses.

Reimbursement happens when you use the services of an out-of-network professional, you bore most of the cost, and you want your insurer to pay you in cash for the part they were to cover.

Can an ACA Health Insurance Company Refuse to Pay a Claim and What Can I Do About it?

Yes, an ACA health insurance company can refuse to pay a claim. However, it must let the insured know the reason for the denial and how you can dispute their decision. Depending on the reason, in Texas this information is usually given within three to 30 days. If the insured believes that the denial is unjustified, they can appeal the decision. The right to appeal the claim denial can be exercised in two ways:

Internal Appeal

You have the right to file an internal appeal with your insurance company if they deny your claim. You can request that your insurance company performs a thorough and impartial review of its decision. You need the following to file an internal appeal:

  • Fill out all applications and forms required by your insurance company. Alternatively, you may write your insurer with the necessary information about the claim, including your name, claim number, and health insurance ID number.
  • Present all other additional information that you feel your insurer should take into account—for example, a letter from the doctor.
  • You can get the assistance of the Texas Department of Insurance in filing the appeal by calling (800) 252-3439.

The appeal should be filed within six months of receiving the denial of claim from your insurer. An appeal for a service that you have not gotten will be completed within 30 days. For a service you have gotten, you should get a verdict within 60 days. If the situation is urgent, your insurance provider must accelerate the process. If the usual appeal process would put your life or your ability to regain maximum function in jeopardy, you can seek an expedited appeal. A final decision on your appeal must be made as soon as your medical condition permits, but no later than four business days after your request has been submitted. This final decision can be made orally, but it must be followed up with a written notification within 48 hours.

Your insurer will give you a written verdict after the appeal. If they uphold the denial of your claim, your insurance company must include instructions on how to request an external appeal. You may decide to undertake the external appeal process.

You will need all the records and information relating to your claim and its denial for the external appeal. This includes the following:

  • Explanation of Benefits forms and papers that detail what payment or service was denied.
  • A record of the internal appeal request that you made to your insurer
  • Any documents you supplied to your insurer that contained extra information (like a letter or other information from your doctor)
  • If you prefer to have your doctor or someone else file an appeal on your behalf, a copy of any letter or form you need to sign.
  • Notes and dates from any phone interactions you have about your appeal with your insurance company or doctor. Include the date, time, name, and title of the individual you spoke with, as well as the specifics of your interaction.
  • Keep the original documents and send copies to your insurer. You will need to give the insurer your original internal appeal request and your request to have a third party (such as your doctor) file your internal appeal on your behalf. Ensure that you have a copy of each of these documents.

An internal and external appeal request can be filed simultaneously.

External Appeal

You have the option of having your appeal reviewed by an independent third party. This means that your insurance company no longer has the final decision on whether or not to pay a claim after an external review. You can file an external review by submitting a written request for an external review within four months after determining your internal appeal. The external reviewer makes the final decision, which can either be in or against your favor. Your insurer must accept the external reviewer's decision. You can contact the Texas Department of Insurance to help you with the external appeal process by calling (800) 252-3439.

Decisions that go to the external appeal stage include:

  • Any denial involving a medical decision in which you or your provider disagrees with the health insurance plan
  • Any denial based on the fact that a treatment is experimental or investigational.

Why Do ACA Insurance Companies Deny Insurance Claims?

ACA-compliant insurance companies in Texas deny insurance claims for the following reasons:

  • When the claim is for a benefit that is excluded from your health policy
  • If, according to the insurance provider, you provided inaccurate or incomplete information when you applied for coverage, consequently your coverage was cancelled back to when you enrolled.
  • If you had the medical problem long before you signed up for your coverage
  • Services or treatments that are considered "not medically necessary", "experimental" or "investigative."
  • When you are no more part of the plan.
  • When you get services or supplies from an out-of-network provider or institution.

What are the Top Reasons an ACA Claim Might Be Denied for Payment in Texas?

The most common reason your claim may be denied in Texas is that the claim is for an excluded service. That is, the service provided is not considered part of your plan. Other common reasons include denial because of lack of prior authorization or referral and because the service was not a medical necessity.

How Much Does ACA Insurance Pay Out?

There is no set fee or amount that your insurance company pays out for claims. It usually depends on different factors, including the amount billed by the provider, the plan you are on, your policy terms, and the negotiated rate between the insurer and the service provider..

What if My Insurance isn't Paying Enough for My Claim?

If your insurance is not paying what is required for your claim, you can report this to the Texas Department of Insurance or the health insurance Marketplace. To report to the Department of Insurance, you can file a complaint through the online Insurance Complaint Process or call (800) 252-3439. For the Marketplace, you can call (800) 318-2596.

If these methods do not work, you may be able to sue your insurer, if it violates or fails the terms of your insurance policy.

How Can I Check the Status of My ACA Insurance Claim?

Usually, you can login into your account via the insurer's member portal and see the up-to-date claim status there. Alternatively, you can discuss your issue with your insurer's Customer Support.

Do I Need to Tell the ACA Insurance Company if I am Diagnosed with an Illness that My Coverage Excludes?

Yes. Although your ACA plan provides you with wide coverage, including emergency, treatment, preventive services, and pre-existing conditions, it is generally advisable you contact your insurance company if you are unsure about the policy's coverage. This is to prevent a misunderstanding regarding the terms and coverage of your plan.

When not to File an ACA Insurance Claim?

You should know your ACA insurance policy because it is not advisable to file a claim for something not covered by your policy. While your ACA plan provides you with comprehensive coverage, including pre-existing conditions, there are things your coverage may exclude. For example, your ACA plan may not cover abortion services or long-term care. You should not file a claim in cases like this because your insurance policy does not cover such services.

Unlike other types of insurance in Texas, your claims history does not cause an increase in your ACA insurance premiums. However, you should not make claims for things you know are not covered in your policy.