The health insurance claim process, explained

A health insurance claim is a request for consideration for benefit application that your healthcare provider usually submits to your health insurance company following a visit. Because several parties are involved in this process (namely, you, your provider and your insurance company), the health insurance claim process can sometimes be confusing. Below, we explain how health insurance claims processing works, what the health insurance claim process looks like and how to navigate it. 

Main Takeaways 

  • A health insurance claim is a bill that a healthcare provider submits to an insurance company to request payment for services or products given to a patient.
  • Usually, a healthcare provider’s office will submit the claim; occasionally, however, the patient must do it themselves.
  • After a claim is processed, the patient receives an Explanation of Benefits, which outlines what the insurance plan paid and what the patient may still owe.    

What are health insurance claims?

If you’re wondering, “What is a medical insurance claim?” you’ve come to the right place. Simply put, a health insurance claim is the name for a bill for the healthcare services or products that you received, and it’s a key part of the medical insurance claim procedure. A claim isn’t sent to you, the patient, however. It’s usually sent by your provider to your health insurance company.

Types of insurance claims

There are several types of medical claims that can be submitted, depending on the care that you receive. Examples include: 

  • Preventive care claims, such as annual exams, vaccinations and cancer screenings
  • Medical treatment claims, such as visits to a doctor, urgent care, emergency room or hospital stays when a person is injured or sick, along with medical tests and procedures
  • Pharmacy claims, which include prescription medications
  • Specialty claims, which may include services received for dental and vision care
  • Travel benefit claims, in the event that a person gets sick on a trip abroad 

What does healthcare claims processing look like?

To understand healthcare claims processing, it’s helpful to examine the life of a claim. This can involve several steps, and may take several days or weeks as the claim travels from your provider to your insurance company and ultimately to you. Let’s have a look.

How to file a health insurance claim 

  • Frequently, a patient won’t need to file a claim because the provider handles how to submit a health insurance claim on their behalf. During an appointment, the provider will note several critical details, including diagnoses, tests and services performed, each of which will also have a billing code. That information is then included in a claim, which is sent to the insurance company for consideration for a benefit application. 

Who submits a claim? 

  • As mentioned, usually the medical insurance claim procedure is initiated by the healthcare provider’s office. However, if the provider is out-of-network, the patient may need to learn how to file a medical insurance claim and submit it themselves.
  • If you are sending a claim to the insurance company as a patient, you’ll want to access the proper forms to fill out. If you’re a Blue Cross Blue Shield of Alabama member, you can get those by calling customer service (the number is listed on the back of your insurance card) and ask about how to submit a bill to insurance, or you can submit a claim in your myBlueCross account for medical expenses, dental expenses, vision or hearing, pharmacy and travel benefits. Be sure to file the claim in a timely manner following the service. 

 What happens when a claim is submitted? 

  • When the insurance company receives a claim, a claims processor will review the request as part of the healthcare claims processing workflow and decide if the items listed are covered by your policy. If it is covered, the insurance company will then pay the allowable amount. The health care provider will then bill you for any remaining amount, such as co-insurance, copay or your deductible. 

What is an explanation of benefits? 

  • Many people wonder, what is an Explanation of Benefits? As the claim moves along in the system, the patient will receive what’s called an Explanation of Benefits, or EOB, which is a document sent by your insurance company and details how your health insurance plan is paying for your care, what it is denying (if anything), what each service costs and any balance you may owe.
  • The Explanation of Benefits is not a bill, it’s simply a detailed explanation. However, you may receive a bill from your doctor’s office. If and when you do, be sure to compare your Explanation of Benefits to the bill and make sure they are consistent. If they are, pay the bill promptly. If they don’t match, call your insurance company and doctor’s office to find out why. 

What are claims denials?

A claim denial occurs when an insurance company decides not to cover a service or treatment. In some cases, the treatment or procedure may not have received prior authorization from the insurance company; or the insurance company may consider the procedure not medically necessary; or a drug may be denied because it’s not covered by your plan. In order to avoid having claims denied, it’s best to check with your health care provider and insurance provider before a service or procedure, so you’re aware of what your plan does and doesn’t cover.

However, if your claim is denied or your medication isn’t covered, you can request that the decision be reviewed or request an exception. Start by calling the customer service number on the back of your insurance card to learn more about why something has been denied and ask about next steps.

Learn more about how health insurance works, beyond health insurance claims

Understanding the health insurance claim process and healthcare claims processing steps can help you to feel more confident in putting your health insurance policy to use. Now that you have the answer to “what is a claim in health insurance,” you may want to explore other resources that can help you make the most of your coverage. Here are some other great reads about health insurance claims and beyond to help you act as your own best advocate: