What is a Health Insurance Claim?

All About Health Insurance Claims and the Claim Filing Process

Health insurance helps patients get the medical care they require
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A health insurance claim is how you or your health care provider communicates to your health insurance company that you’ve received a health care service you believe is covered by your insurance policy. Health insurance claims are an important piece of your relationship with your health insurance company and are the primary form of communication when it comes to using your health insurance benefits.

Information Included in a Health Insurance Claim

A health insurance claim is much like a detailed invoice in that it details exactly what health care services you received as line items along with the requested payment amount. Each line item will typically include other important information like the date of service, description of service, and the medical billing code. The insurance claim will also include information about the provider.

The claim will also include information like the policyholder's name and identifying information like member number, birthdate, or even a social security number. It will also include information about the insured (or person who received the service), if not the same as the policyholder (as is the case with spouses or dependents on the plan).

Health Insurance Claim Process

The process of notifying your health plan about this medical bill is called “filing a claim.” The process of filing an insurance claim is difficult to outline as the steps vary depending on several factors like your health insurance plan, your plan's guidelines for filing a claim, and even your health care provider's contract with the insurance company.

Filing a Health Insurance Claim

Although you may file the claim yourself, your doctor or health care provider will often file the claim for you. This is most common when you use in-network providers. If you use an out-of-network provider, the provider might file the claim for you or they might not. You’ll have to ask.

If your out-of-network provider doesn’t file the claim, you’ll have to do so. Most health plans have a paper or online form they require for filing a claim. To fill out the claim form and file the claim yourself, you’ll need information like the doctor or health care provider’s name and address, the date you got the care, and the insurance codes used to define your diagnosis and what kind of service your doctor provided. You can learn more about these insurance codes in “Learn About Insurance Codes to Avoid Billing Errors.” Make sure to ask for - and verify - those insurance codes. Your insurer might also want the provider’s tax identification number.

After You File a Claim

Sometimes health insurance companies will ask for more information after the claim is initially submitted to complete the processing of the claim. Don’t be nervous if this happens. It doesn’t necessarily mean something is wrong. In fact, a request for more information is fairly common.

After your health plan finishes processing the claim, it’ll send you an explanation of benefits (EOB).

The EOB will show you what services the claim was for, how much the bill was, what the insurance company paid, and how much you’ll be required to pay in the form of deductible, copay, or coinsurance for this particular claim.

To learn more about health insurance claims and the claim process, see our other articles:

Filing Your Health Insurance Claim Form

Fighting a Health Insurance Claim Denial

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