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Direct Payment and Reimbursements in Health Insurance


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What is the difference between Direct Payment and Reimbursements?


How does the insurance policy function, and how will I receive the promised benefits and payments? Health insurance policies operate in two ways: direct payment or reimbursement.

What is Health Insurance Direct Payment?


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This is when the hospital bills the insurance directly for the insured's hospitalization. This is accomplished through agreements between the insurance company and the hospital, in which the hospital asks consent from the insurance company to fund the insured during the hospitalization, and the insurance company then pays the cost.


The insurer issues a letter of authorization detailing which expenditures it allows and will cover, as well as which it must charge the insured, including the applicable deductible and coinsurance. The insured will only be responsible for the deductible and coinsurance, as well as any uninsured charges.

What is the definition of Medical Insurance Reimbursement?


reimbursement in health insurance

Reimbursement, on the other hand, entails the insured incurring expenditures and then seeking reimbursement from the insurer with the necessary paperwork, forms, and invoices in the policyholder's or insured's name. The insurer will subsequently authorize and pay the reimbursement by transferring funds to the insured's account, while keeping the deductible and accompanying coinsurance.


Some expenditures, such as drugs or expenses unrelated to the sickness, will also be deducted by the insurer. According to the tabulator contracted with the policy, it may also tabulate medical expenditures such as consultation fees to pay up to the maximum.

Is it possible to make Direct Payment and Reimbursement on the same claim?

Of course, you can. In fact, it is very common for the insured to be operated on in the hospital and upon discharge apply direct payment, paying only the deductible and coinsurance.

Subsequently, the expenses incurred before and after the hospitalization and which are directly related to the illness, such as studies, laboratory tests, consultations, medicines, will be reimbursed through the normal process, with one difference: the deductible will no longer be charged, since it has already been paid at the hospital.

How do I process a Reimbursement?


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Don't worry, if you employ a competent insurance agent, he or she will be able to clearly clarify the procedure to elaborate a reimbursement, the papers to be filled out by your doctor, the ones you must fill out, and the documents that must be attached (invoices, test results, hospital statement, medical prescription).


If you do not yet have Medical Insurance, or if you want to examine a better choice for you and your family, meet Elite Insurance, the appropriate insurance provider to keep you safe at all times.



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