How to File an Insurance Claim: A Step-by-Step Guide

Navigating the insurance claim process can be intimidating — especially when you’re already dealing with a stressful event like illness, injury, or a property loss. At Resolute Insurance Advisors, we believe that clarity and preparation can make a major difference in how smoothly your claim goes. Below is a detailed walkthrough of the claim-filing process, including what documentation you’ll need, key timing considerations, and practical tips to help ensure your claim is handled efficiently and fairly.

Understand What Kind of Claims We Handle

At Resolute Insurance Advisors, our core focus is on health and dental insurance — for individuals, families, and small businesses. Resolute Insurance

That means the claims many of our clients will file involve medical services (doctor visits, hospital stays, surgeries), dental work, prescriptions, and possibly other covered care such as behavioral health or long-term disability under certain plans. Resolute Insurance

Because your coverage is tailored to your plan (HMO, PPO, HSA, etc.), the claims process for health/dental tends to differ — sometimes considerably — from auto, home, or property-damage claims. That said, many core principles remain universal: prompt reporting, good documentation, clear communication, and understanding your policy.

That’s why the steps below — while broadly applicable — put extra emphasis on best practices relevant to health and dental claims, while also offering general guidance that works across different claim types.

Step 1: Review Your Policy and Know What’s Covered

Before anything else, take a close look at your insurance policy — or contact your agent at Resolute — to confirm:

• What types of care or losses are covered. For health plans: doctor visits, hospitalizations, prescriptions, mental health services, etc. For dental: cleanings, fillings, maybe orthodontics depending on your plan. Resolute Insurance

• Deductibles, co-pays, co-insurance, and out-of-pocket maximums. Knowing these helps you understand up-front what you’ll pay, and how much the insurer is responsible for.

• Any special conditions or limitations. For instance: whether pre-authorization is required for certain treatments, or whether certain providers are in-network.

• Deadline or timing requirements for filing claims. Many insurance policies require you to file promptly — the exact wording could be “immediately,” “within a reasonable time,” or something more specific. Insurance and Safety Fire Office

Tip: Keep a digital or physical folder with a copy of your policy along with the contact information for your insurer (or your Resolute advisor). Having that on hand when you need it — especially if you’re unwell, under stress, or otherwise occupied — makes a big difference.

Step 2: When the Need Arises, Notify Your Insurer Promptly

As soon as you receive medical care (or incur a loss), or as soon as you discover a covered event, reach out to your insurer or agent. For health and dental claims, this often means submitting a claim for reimbursement or having your provider bill the insurer directly. The sooner you notify the insurer, the better.

Delays can complicate or even jeopardize your claim — many insurers expect prompt notice. Insurance and Safety Fire Office

If you work with Resolute, contact your advisor as soon as possible: we can help guide you through the documentation you’ll need and ensure the claim is filed correctly.

Step 3: Gather and Submit the Necessary Documentation

A successful claim rests on solid documentation. The kinds of paperwork (or digital records) you’ll typically need for health/dental claims include:

• Itemized bills or invoices from the provider (doctor, hospital, dentist, lab, etc.). These should list the date of service, procedures performed, CPT codes if applicable, and amounts charged.

• Explanation of Benefits (EOB) forms, if the insurer has already processed part of the claim or co-paid.

• Proof of payment or receipts — if you paid out-of-pocket for services and are seeking reimbursement.

• Medical records or treatment summaries, if required — especially for hospitalizations, surgeries, or treatments requiring pre-authorization.

• Any pre-authorization or referral paperwork, where applicable (depending on plan type).

• Copies of correspondence with the insurer, including claim numbers, adjuster names, dates of contact, and notes from phone calls or emails. It’s wise to record the name and title of the person you spoke with, and a short summary of what was discussed. Insurance and Safety Fire Office

  
  

For transparency and safety, keep copies of everything you submit. If possible, use certified mail, a portal with tracking, or another method with proof of submission, to make sure there’s a paper trail.

Step 4: Work With the Insurance Adjuster or Claims Reviewer

Once your claim is submitted, many insurers assign a claims adjuster or reviewer. Their job is to: verify documentation, check that the claim fits within the terms of your policy, and determine what portion — if any — they will reimburse. This step often includes:

• Reviewing your submitted documents (bills, receipts, medical records, EOBs).

• Confirming eligibility (e.g., was the service covered? was it “in-network”? was pre-authorization obtained if required?).

• Checking for overlapping coverage — for example, if you have multiple insurance plans, they may apply the principle of “coordination of benefits.” Wikipedia+1

• Sending back a notice of approval, partial approval, or denial — along with an explanation.

  
  

In many cases, this review happens within a short time, and simple claims may be resolved within days or a couple weeks. Acrisure

If your claim is large, complex, or involves treatments requiring extra review — like hospitalizations, surgeries, or long-term care — the process may take longer.

Step 5: Review the Decision and Follow Up (if Needed)

Once your insurer provides a decision:

• If approved: check the payment or reimbursement amount carefully. Confirm that it matches the services rendered, minus any deductible, co-pay, or co-insurance.

• If partially approved or denied: carefully read the reason — insurers are required to explain denials. Insurance and Safety Fire Office+1

• If you disagree with the decision or think something was overlooked, don’t hesitate to contact your agent or the adjuster. Ask for a full explanation and request the specific policy language under which the denial was made. Insurance and Safety Fire Office

• If your policy allows it, you may be able to appeal or submit additional documents (for example, further medical records, proof of necessity, or corrected coding).

  
  

Key Timelines & Deadlines: What to Know

Because you live in Colorado — and insurance laws vary by state — it’s critical to check your specific policy. But here are general guidelines and common practices worth noting.

• Many claims must be reported as soon as possible, often immediately or “within a reasonable time.” Delays can result in a denial. Insurance and Safety Fire Office

• Once the insurer receives your claim, many auto and property insurers aim to investigate and respond within ~30 days. While health/dental claims often move faster, the principle of prompt resolution still applies. Progressive+2Acrisure

• For certain types of claims — especially involving injury or property — other laws might define a “statute of limitations,” which limits how long you have to file a claim or lawsuit. For health insurance, you’ll rarely be dealing with lawsuits — but for other claims, this may matter. Oksenendler Law+2TrustedChoice.com

  
  

Bottom line: sooner is better. Filing early helps keep evidence fresh, ensures paperwork is more accurate, and strengthens your case if there’s any follow-up needed.

Helpful Tips to Maximize Your Chances of a Smooth, Successful Claim

From years of working with clients, we at Resolute frequently see avoidable mistakes. Here are some of our top tips:

• Don’t wait. As soon as the event occurs (a doctor visit, treatment, dental work, etc.), start gathering documentation.

• Stay organized. Use a folder (digital or physical) for bills, receipts, medical records, EOBs, and correspondence.

• Take great notes of all communications. Write down names, dates, and summaries of conversations with the insurer or your agent.

• Avoid “permanent fixes” before inspection. For property or injury-related claims: if there’s damage, avoid making permanent repairs before an adjuster reviews it — you don’t want to undermine your claim. Insurance and Safety Fire Office+1

• Be ready to negotiate if needed. If the first offer seems low, ask for a detailed, itemized explanation. Be polite but persistent — you have the right to ask for clarity. Insurance and Safety Fire Office+1

• When in doubt, call your agent. That’s what we’re here for. Whether you have questions about coverage, timing, or paperwork — a quick call can save you weeks of headache.

  
  

When You Should Consider Getting Help from a Professional

Most health or dental insurance claims — like a routine doctor visit, lab test, or dental cleaning — are straightforward. But sometimes claims get complicated: major surgery, hospitalizations, treatments requiring multiple providers or specialists, or services needing pre-authorization.

In those cases, having someone on your side — whether it’s your insurance agent, a patient-advocate, or even a legal professional — can make a big difference. They can help you:

• Interpret confusing coverage terms

• Collect the right documentation

• Negotiate fair reimbursement

• Appeal denials if needed

  
  

At Resolute Insurance Advisors, we’re happy to provide that kind of support.

The Bottom Line: Preparation, Promptness & Persistence

Filing an insurance claim doesn’t have to be a headache — but it can feel that way if you’re unprepared, disorganized, or uncertain. The smoother claims come from those who act quickly, keep detailed records, and stay on top of communication.

If you are a Resolute client — or thinking of becoming one — remember: we’re not just about selling plans. We’re here to help you use them effectively when the time comes.

So when a doctor’s visit, hospitalization, or major dental procedure comes up, don’t wait. Review your coverage, gather your documents, reach out — and let us help guide you through it.

With the right preparation and a clear process, getting the benefits you’re entitled to becomes a lot less stressful. And that’s precisely why we’re in this business.