Health Insurance Claim Form: Example PDF

LJ Acallar

September 5, 2025•13 min read

Fact checked by Dr. Ben Condon

Template

Health Insurance Claim Form

This health insurance claim form enables clinicians to directly submit to insurers the details of health service coverage to be reimbursed after delivering care to patients. It follows the typical format, including personal, medical, and financial information. This AI-powered health insurance claim form can:

Streamline GP’s billing workflow by ensuring that claims are aligned with insurance policies
Make for a clean claim, ensuring ICD-10 diagnostic codes are accurate to avoid delay in payment
Help practitioners ensure fraud vigilance to keep integrity and patient trust

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What is a Health Insurance Claim Form?

A health insurance claim form is a formal request sent by health professionals to insurance companies, which is essential in billing documentation. These forms help ensure financial security for beneficiaries after they receive care.

Most Common Types of Health Insurance Claim Forms

Health insurance claim forms differ in scope, but among the most commonly used in the US are the CMS-1500 and the UB-04. Additionally, it is noteworthy that it is standard in healthcare practices to comply with HIPAA to ensure that electronic claim formats protect patient data. Care providers can do the traditional paperwork, but with the increasing healthcare demands, it is far more efficient to submit claims online.

Average Turnaround Time for Processing Health Insurance Claim Forms

Insurers often have strict deadlines for filing health insurance claim forms, typically around 90-180 days from the date of service. Delays or denials for claims can create friction between providers and patients, and this is where Heidi highlights support. With Heidi, integrated claim submissions make for a more efficient way that saves time for care providers, insurers, and, of course, patients.

In this article, we’ll discuss why filling out health insurance claim forms is crucial in the administrative aspect of care workflows. We’ll also take a look at real-world examples of health insurance claim PDFs and templates, alongside AI-driven solutions that make documentation more bearable.

The Importance of Filing Health Insurance Claim Forms

The proper submission of health insurance claim forms is vital, as denied claims can significantly impact the ability to maintain quality care.

Denials in claims often stem from procedural missteps, such as missing authorizations, out-of-network care, policy exclusion, or incorrect codes. A report by Experian Health states that last year, 46% of denials were attributed to inaccurate information alongside preauthorization issues.

These concerns, coupled with hurdles in policy changes and payer complexity, contribute to the already mounting pressures in administrative load. This is a burden often at the expense of clinicians. Clinicians have widely adopted AI-powered solutions like AI medical scribes that optimize the documentation process through the use of clinical note templates.

Health Insurance Claim Form Examples

Health insurance claim forms vary in depth for each beneficiary. Below are overviews of real-world sample health insurance claim forms yet to be filled out.

Example 1: Star Health Insurance Claim Form

In India, Star Health is an insurance company offering comprehensive plans for health, accident, and travel. Claim forms in Star Health differ for cashless and reimbursement options. Moreover, document requirements for claims include discharge summaries and hospital bills.

Example 2: Guardian Life Health Insurance Claim Form

Insurance claim forms slightly differ for Guardian Life, in that they have an added option, like employer-provided health insurance. In some cases, health, dental, and vision claims are combined into a single form for submission. In these forms, information about the provider and HIPAA authorization may be key sections that are generally included.

Example 3: Sun Life Health Insurance Claim Form

Sun Life is a large Canadian insurer that offers benefits, including group plans. As an insurance company, Sun Life accepts submissions either through its official online portal or via the traditional paper method. Although it has a claim form intended to cover general medical expenses, dental claims are differentiated by this insurer.

Example 4: Mapfre Health Insurance Claim Form

Mapfre Insurance is a global insurer with a strong presence in Latin America and Spain. Regional counterparts of their forms can be specific with considerations for language or translation. Mapfre Insurance also requires supporting documents like prescriptions and receipts for claims.

Example 5: Cigna Medical Health Insurance Claim Form

Cigna Healthcare is an insurance provider available worldwide, but US domestic plans may have more distinct claim forms. For more accurate claims processing, ICD and CPT codes can be used for this insurer.

Example 6: Horizon Medical Health Insurance Claim Form

Horizon Blue Cross Blue Shield of New Jersey uses a streamlined claim form process designed to work for both in-network and out-of-network medical services. For out-of-network providers, Horizon accepts the CMS-1500 form. Members can log into their online portal to submit claims and supporting documents electronically.

The length and complexity of these forms necessitate longer hours for form-filling. This is why early AI scribe adopters like the Indiana Health Group (IHG) chose Heidi, as it streamlines their administrative tasks. The president of IHG, Dr. Chris Borjab, shares:

"Before, I had to choose between having a crappy note or sacrificing the face-to-face experience with patients… I'd either be madly typing to capture everything or trying to stay present while knowing my documentation would suffer."

Thankfully, they were impressed by how Heidi structured notes from medical jargon and allowed them to engage with patients more meaningfully.

"I purposefully didn't look at your pricing because I decided I'm going to try this for two or three days. And then the question I'm going to ask myself at the end of two to three days is if my practice wasn't going to buy this and if I was going to look at buying it on my own, how much would I pay for it? At the end of three days, I'd be like I would pay $1,000 a month for this for my quality of life."

How to Fill Out a Health Insurance Claim Form

While there’s no one-size-fits-all health insurance claim form, the beauty of Heidi AI is that it’s adaptable to any practice and highly customizable across 200+ specialties. Below are five easy steps on how Heidi’s form-filling features can help you complete a health insurance claim form and save more time:

Step 1: Upload structured form PDF

From your Heidi account’s template library, click “Create template.” Select “Fill a PDF form” and upload your PDF file by clicking through or dragging and dropping it. Ensure that your form is correctly structured for autofill, as image-based PDF files may be incompatible.f

For the best results with form filling, include clear field names, conditionals, and descriptions in your PDF. View formatting guide.

Step 2: Edit PDF form template details

As Heidi analyzes the details of your health insurance claim form PDF, you can edit the template name and its visibility, then click “Save template” to finally create it. Take note that the visibility of your form is set to “Only Me” by default, but it can also be shared across your team.

Step 3: Use Heidi PDF Templates on your notes

When you finish a session, click “Create” to look for the blank PDF form you just uploaded. You can select the document you uploaded under “PDF Templates,” and it will automatically direct you to a loading display screen while it generates. The PDF Template will be present in your next sessions, along with other forms you added to your template library.

Step 4: Heidi auto-completes form fields instantly

That’s practically done. Heidi will prepare your filled-out PDF form, matching your session details to its respective fields. While it prepares your auto-completed form, you also have the option to stop generating.

Step 5: Download your completed PDF form

As Heidi finishes up in auto-populating your PDF form, all you gotta do is hit “Download PDF.” Alternatively, you can allow permission for Heidi to auto-download your files so they go directly into your local downloads folder.

Health Insurance Claim Form Sample PDF

Sample PDF automatically filled by Heidi for demonstration purposes only. No PHI or PII was used. Content is from a simulated session and not based on real individuals.

The intricacies of health insurance claim forms contribute to how complex and time-consuming they can be to fill out. On average, general practitioners see 80-100 patients in a typical week. Clinicians are left with a significant amount of mounting billing burden, even if a chunk doesn’t bill or pays out-of-pocket.

Easily Fill Out Health Insurance Claim Forms with Heidi

Online submission of insurance claim forms reduces the need for manual paperwork and billing processing time. Heidi offers this convenience by providing you with several health insurance claim form templates. With Heidi AI, not only can you easily fill out these claim forms, but you can also own the platform and customize it according to your needs.

Using Heidi benefits you in more ways than you can imagine:

Specialty-specific solutions: Psychologists need long formats, surgical specialties need structured templates. Either way, everyone has a legitimate need to document more efficiently. Heidi’s compliant AI solution responds to this need by ensuring consistent, high-quality documentation is in place.
Shorter sales cycle: Optimizing billing processes significantly contributes to the overall care delivery impact. Heidi addresses inefficiencies, such as payer complexity, by effectively tracking patient retention and long-term value.
Reduced cognitive load: Documentation should take up fewer hours of every clinician’s day to deliver better care. Using Heidi takes one patient conversation to generate the rest of the documents you need.

Heidi is a globally trusted platform that helps clinicians with over two million patient consultations every week. Our AI scribe solution meets international healthcare data and security standards, such as HIPAA, PIPEDA, GDPR, the APP, and more.

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Frequently Asked Questions about Health Insurance Claim Forms

What is the difference between a hospitalization claim form and a medical treatment claim form?

While both insurance claim forms require medical information, the difference lies in who needs to submit these claims. Generally, hospitalization claim forms like the UB-04 are filed by institutional healthcare providers, covering facility-related charges. On the other hand, medical treatment claim forms like the CMS-1500 need to be filed by an individual physician, as the form highlights charges for professional services.

What claim form is used for billing physician claims to commercial health insurance companies?

For individual physicians billing commercial health insurance companies, the claim form called CMS-1500 is most commonly used. This medical treatment claim form is standard, collecting healthcare information, including details about the provider, services, and costs. Provided by the Centers for Medicare & Medicaid Services, this electronic form ensures compliance and billing accuracy, especially made easier by Heidi AI.

What claim form is used for hospital claims?

For hospital claims, the claim form used to bill private insurers is called the UB-04, also known as the uniform billing form. The form, which is the official form for the Centers for Medicare and Medicaid Services, has become the standard form that institutional healthcare providers use. Heidi’s AI reduces procedural errors in filling out this 80-line form, making the hospitalization claim process faster.

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