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Health Insurance Basics

Your Simple Guide to Understanding the (Not-So-Simple) Health Insurance Claims Process

April 13, 2018

Have you ever wondered what happens to a medical insurance claim once it leaves your doctor’s office? This infographic walks you through the process so you know the steps and what to expect.

Infographic Text


What is a Claim?

Simply put, a claim is what a doctor submits to your insurance company so they can get paid. It shows the medical services that were provided to you.

Submitting a Claim Yourself

Typically, your doctor or provider, especially if they’re in your plan, will submit the claim for you. In rare cases when you visit a doctor outside your plan, you may have to do this yourself.

Here are some steps to make sure your claim gets processed smoothly

  • Make sure to use the claim form from your benefits plan
  • Include all necessary information, including procedure codes (you can get these from your doctor’s office)
  • If you’re filling the form out by hand, write legibly
  • File your paperwork promptly and within the time limit
  • Include preapproval (if needed)
  • Verify the treatment claim is covered by your plan
How Does Claims Processing Work?
  • After your visit, either your doctor sends a bill to your insurance company for any charges you didn’t pay at the visit or you submit a claim for the services you received.
  • A claims processor will check it for completeness, accuracy and whether the service is covered under your plan.
  • If the service is covered in your plan, the insurance company pays the claim – sometimes the entire cost and sometimes a portion depending on your benefits. You’ll be responsible for paying any remaining portion.
  • The claims processor also verifies important information like your copay and how much of your annual deductible and out-of-pocket maximum you’ve already paid.
What Happens After the Claim is Processed?
  • You will receive an Explanation of Benefits (EOB) that details how the medical care you’ve received is being paid by your plan.
  • Around the same time, your doctor may send you a final bill for services. (Tip: Don’t mistake your EOB for a bill.)
  • Pay your doctor promptly, but only after comparing the services listed on the final bill with your EOB. What you owe and the amount on the bill should match. If not, call your doctor’s office.

Claims processing may seem complicated but making sure you provide all needed information makes it go more smoothly.