Practice Tool

Should We File Medical?

Answer seven questions about the card in your hand and get a clear answer — with the reasoning shown, not just a verdict.

Free, no sign-in No patient information About 2 minutes
Step 1
Is this the medical card?

A copay grid or an RxBIN means medical. A card that only says “Dental” cannot file a medical claim.

Step 2
Are we in network with this plan for medical?

Being in network on the dental side says nothing about the medical side.

Step 3
What plan type is printed on the card?

Read it off the card. HDHP is a deductible structure, not a network — pick the network type underneath it.

Step 4
Did the plan confirm out-of-network benefits for these services?

Ask Provider Services, not Member Services. Skip if we are in network.

Step 5
Referral or prior authorization

An unreferred claim denies even in network on an HMO or POS.

Step 6
The deductible, against this case

Use the out-of-network deductible when we are out of network. Leave at zero if it is met.

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Step 7
Who does the plan pay?

Many plans mail the check to the member on out-of-network claims.

Recommendation

File the medical claim

What decided it

    This is a screening aid, not a coverage determination. It weighs what the card and the benefits call tell you; it does not decide medical necessity, diagnosis, or coding. MediClaim Works does not review or determine claim content; diagnosis codes, modifiers, and service qualifiers are selected by the provider or billing professional. Plan rules, state law, and payer policy change — verify current requirements with the payer and your state.