How Does the Health Insurance Claims Process Work? | eHealth

An insurance claim is what a doctor submits to your insurance company after providing you with a procedure or service so they can get paid. The claim will list the medical services provided to you.

How does the insurance claims process generally work?

Usually, your doctor’s office will file a claim and you won’t need to be involved in the process. your doctor will bill your insurance company for charges you did not pay during a visit or file a claim for services provided during your visit.

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then a claims processor will verify it. They verify that the claim is complete, accurate, and whether the services are covered by your health insurance plan. They’ll also check other important information, like your copay and how much of your annual deductible and out-of-pocket maximum you’ve already paid during the year.

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If the service is covered, the insurance company will pay the doctor. depending on the benefits included in your health insurance plan, they will pay the full cost of the service or a part.

after the claim is processed, you will receive an explanation of benefits (eob) detailing how your plan paid for the care you received. You may also get a bill from your doctor during this time for any charges not paid by you or your insurance company.

After you receive your final bill from your doctor, compare your final bill to your EOB. The information on the EOB must match the amount you owe your doctor as stated on the bill.

Do I ever have to file an insurance claim myself or does the health care provider take care of that?

Usually, you will not have to file a claim yourself. most health care providers take care of this process. however, if you ever need to file an insurance claim yourself, here are some tips to ensure your claim is processed smoothly:

  • write clearly and legibly
  • submit your paperwork immediately and within the time limit
  • if necessary, include prior approval
  • includes all necessary information
  • include procedure codes (you can get these from your doctor’s office)
  • be sure to use your benefit plan claim form
  • verify that the services you received are covered by your specific plan
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    Other than having to file the paperwork yourself, the claim is processed the same way. however, you may need to pay your doctor up front and wait for reimbursement from your health insurance company.

    Does my type of health insurance plan affect how the health insurance claim process works?

    You can expect your claims process to work the same from one insurance provider to another. however, if you must pay up front and file your claim after receiving care, you may have to wait for your health insurance company to reimburse you.

    Check with your health insurance company and health care provider to fully understand how they process claims and handle payments.

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