7 Must-Know Spanish International Insurance Policy and Claim Terms

Navigating the Mexican healthcare system can feel like learning a new language. 

But don’t worry, we’ve got your back.

Mastering these key Spanish international insurance policy and claims terms will not only make your doctor visits smoother, but also streamline the often-tricky international insurance claims process. 

And help you not get blindsided because you think you know how your policy works, but you aren’t clear on a key term or two. 

Below are 7 Spanish international insurance policy and claims terms you need to know if you have international insurance in Mexico. 

We’ve included example documents, but note that these are just examples. The exact layout may look different depending on the doctor and the clinic.

#1 Factura 

This is the official electronic invoice for Mexico. 

And it’s the most important document you need to file a claim. Because it is the document required by ALL international insurance companies when you file a claim.

Without a factura, you’ll be out-of-pocket for medical procedures.

Here’s what you need to know: 

• A proper factura will have the provider RFC, SAT certificate number, and an informational QR code.
  
• The factura is tied to SAT and Hacienda, the Mexican tax departments. Many businesses will avoid giving you a factura to avoid declaring profit.
  
• An RFC number is required to request a factura. The RFC number is a tax ID. It stands for Registro Federal de Contribuyentes.
  
• Preferably you have a personal RFC, but since many expats don’t make a Mexican income or pay Mexican taxes, they aren’t required to register for the RFC and can use the Publico General ID number.
  
• If you have issues obtaining a factura, contact your broker for assistance. By law, every business has to give you one if you ask for it.
  
• All taxes are done monthly in Mexico, which means the factura is typically only available during the month of service. This means you must get the factura the month of your appointment(s).
  
• Make sure it includes the doctor’s name and license number, your name, the date of service, a detailed description of the services provided, and the total cost.
• Best practice is to make sure you request the factura while you are checking out to avoid any issues.

Bottom line: Getting the factura is the right of everyone who asks for one.

Understanding the law and the process gives you a leg up for your claims.

 

 

#2 Pagado (Estampado)

The second Spanish international insurance policy and claims terms you need to know is the pagado.

This is the stamp or mark indicating “paid” for cash payments.

If you’re paying in cash, you will most likely receive a handwritten receipt from the doctor or clinic. Make sure there is a clear “pagado” stamp on the receipt as that is your proof of payment.

While the factura (which is required) will state your payment method, your insurer may ask for all your receipts to complete evaluating your claims.

 

#3 Desglose 

This is an itemized bill, sometimes called factura detallada.

For any hospitalization, the itemized bill of the hospital fees is required. Insurers can also request the itemized bill for medical tests and medications to ensure they are covered by your policy.

Click here to check out an example desglose.

It’s essential to have a detailed breakdown of charges for each service or medication to avoid any confusion with your insurance company.

 

#4 Nota

Medical notes or records are sometimes referred to as informe médico.

This document is required for almost every claim – and it’s your responsibility as the patient to request a copy of these “notas” for your insurance claim.

To file a claim, you will need the complete nota from your doctor on their letterhead.

The note will need to clearly state:

• The date of onset of symptoms.
• Complete evolution of the diagnosis.
• Recommendations for treatment.

If any tests were needed to complete the diagnosis, you will need the written test report.

 

#5 Carta de Garantia – BMI example doc, Redbridge example

This is a letter of guarantee from your insurance company, referred to as the GOP, guarantee of payment.

The GOP is for any pre-certified medical event and also determines if it will be covered by the policy.

For planned procedures or hospital stays, be sure to pre-certify them and make sure your insurer can provide the carta de garantía to the hospital.

 

#6 Receta

This is a written prescription for lab work, tests, images, medication, and referrals.

It is required by the insurer for these types of claims. Make sure you understand the instructions on the “receta” (how to take it, dosage, etc.).

Bonus Pro Tip: Take photos of all your medical documents, including receipts and prescriptions. This serves as a digital backup and can be invaluable if any paperwork gets lost.

#7 UCR (Usual, Acostumbrada y Razonable)

This is a term you most likely WON’T see in policy wording or medical notes. It stands for Usual, Customary, Reasonable costs. 

This references the average cost of a medical procedure within a region, in this case, Mexico.

The information is proprietary to each insurance company so the actual number is not available outside of the insurance company.

This is why pre-certification is so important.

The insurer will negotiate on your behalf with the surgeon and hospital to ensure the costs aren’t over the UCR, potentially saving you hundreds or thousands of dollars out-of-pocket.

 

Additional International Insurance Claim Requirement Terms to Know

Honorarios medicos: Medical fees. This wording is commonly seen on facturas for just about any medical appointment.

Notas de admisión y alta: Admission and discharge notes from any type of hospitalization, including trips to the ER. Another term for admission notes is registro de admisión. Alternatively, discharge notes in Spanish can also be resumen de alta hospitalaria.

Notas Médicas Operatorias: The surgeon’s notes from a surgery. These are needed for any surgical claim.

Nota de Urgencias: Notes from the emergency room which are required if you find yourself needing urgent care.

 

Key Terms Found in Policy and Forms

Below are some Spanish international insurance policy and claims terms you might see within your policy wording, on claims forms, and within pre-certification requirements.

Seguro médico: Health insurance

Prima: Premium

Deducible: Deductible

Exclusión: Exclusion

Reclamos: Claims

Copago: Copayment

Cobertura: Coverage

Asegurado: Insured

Coaseguro: Coinsurance

Presupuesto: Budget (cost estimate in this use)

Descuento: Discount

Laboratorio: Laboratory

Farmacia: Pharmacy

Medicamentos: Medications

Terapia física: Physical therapy

Paciente: Patient

Gastos de hospitalización: Hospital expenses

Cliente: Client

Reclamante: Claimant

Estudio: Studies

Analisis: Analysis

Cirugía: Surgery

Quirurgico: Surgical

Quirofano: Operating room

Oxigeno: Oxygen

Equipo, Equipo medico: Equipment, Medical equipment