Instructions for Completing Your Health Insurance Claims Record

The Health Insurance Claims Record provides a summary of all your bills and payments for your personal files. It’s an easy way to view the portion of each cost (if any) you are responsible for paying each provider. Keep your record up to date by revising it every time you get new financial information about your medical care (you can print out extra copies as needed). If any information is missing, call your provider, your insurer or Medicare to get it.

Download the Health Insurance Claims Record (PDF)

Columns 1-3 (Name/Date of Service/Billed Amount)
Fill in the first 3 columns with the information from your provider’s itemized bill. Even if your provider accepts assignment, you should request an itemized bill. You may need it later to file a claim with your Medigap company or retiree plan if Medicare doesn’t automatically forward it, or if your provider doesn’t file a claim with your Medigap company or retiree plan.

Column 4 (Took Assignment)
Indicate whether the provider accepted assignment. If you are not sure, ask your provider.

Columns 5-6 (MSN Statement Date/Statement Number)
Record the Medicare Summary Notice (MSN) statement date found in the upper right corner of the form, as well as the statement number.

Columns 7, 8, 9 (Amount Approved/Medicare Paid/Met Deductible)
Complete these columns using information from the MSN. Note: Medicare has an annual deductible that must be met before it pays any Part B claims. For more information on annual cost-sharing amounts, see Medicare Basics.

Column 10 (Coinsurance – 20% of Approved Amount + Excess Charges)
If the provider accepted assignment, you only owe 20%. Enter that amount in this column. If the provider did not accept assignment, enter the difference between the amount Medicare paid and the excess charge.

Column 11 (Date Claim Sent)
Enter the date you submitted the claim. If your Medigap company or retiree plan participates in Medicare’s electronic processing program, leave this column blank.

Column 12 (Amount Paid)
Enter the amount of the check you received or the amount the provider received (if your Medigap company or retiree plan sent the check directly to the provider).

Column 13 (Balance Due)
Enter the amount owed.

Column 14 (Date Paid)
Enter the date you paid the bill.

Column 15 (Check Number)
Enter the number of the check you used to pay the bill.

Column 16 (Out-of-Pocket Amount)
You may owe more than the payment you received from your insurer. If so, enter the difference here. Note: You may qualify for an IRS deduction if your out-of-pocket medical expenses are substantial.

Make all payments by check. Pay your portion of the bills by personal check. This way, your cancelled checks and bank statements will provide proof of your payments, as well as backup records of your medical spending. If you receive a check from Medicare, deposit it into your account and write your own check, instead of signing over the Medicare payment to your provider.