Health Insurance Claims Explained: How They Work and What They Mean for You

Understanding what a health insurance claim is can make medical bills far less confusing and help you use your health insurance more confidently. This guide walks you through what a claim is, how it works behind the scenes, and what you can do if something doesn’t look right.

What Is a Health Insurance Claim?

A health insurance claim is a request for payment that you or your healthcare provider send to your health insurance company after you receive medical care.

In plain language:

The claim includes details like:

• What service or treatment you received
• When and where you received it
• The diagnosis and procedure codes used by the provider
• How much the provider is charging

Your insurance company reviews this information and decides how much it will pay, and how much you may still owe, based on your plan’s coverage.

Who Files the Health Insurance Claim?

In many everyday situations, you never file a claim yourself. The process happens behind the scenes.

Provider-filed claims (most common)

In most cases:

• Your doctor, hospital, clinic, or pharmacy sends the claim to your insurance company directly.
• This is often done electronically, quickly and automatically.
• You then receive a bill only for your share (like a copay or coinsurance), once insurance has paid its part.

When you might file a claim yourself

You may need to submit a self-filed claim if:

• You paid for care out of pocket and your provider doesn’t bill insurance (some specialists or out-of-network providers).
• You got care outside your plan’s network, and the provider requires you to seek reimbursement.
• You received emergency care while traveling, especially outside the country.

In these situations, you typically:

1. Get an itemized bill or receipt.
2. Fill out a claim form from your insurance company.
3. Attach required documents (bills, receipts, medical codes if needed).
4. Send everything to the address or portal your insurer provides.

Key Terms to Know Before You Look at a Claim

Understanding a health insurance claim is easier when you know a few common terms:

• Premium – The amount you pay regularly (monthly, for example) to have health insurance.
• Deductible – The amount you must pay for covered services each year before your insurance starts paying more fully.
• Copayment (copay) – A fixed amount you pay (for example, at a doctor visit or for a prescription).
• Coinsurance – A percentage of the cost you share with the insurer after you meet your deductible.
• Out-of-pocket maximum – The most you’ll pay in a year for covered services. After you reach this, your plan typically pays 100% of covered costs for the rest of that year.
• Network – The group of doctors, hospitals, and providers that have agreed to work with your insurance plan, often at lower contracted rates.

These pieces all come into play when the insurance company decides how much of a claim they will pay.

What Happens During the Claims Process?

When you receive covered medical care, a step-by-step claims process unfolds.

1. You get care

You visit a doctor, urgent care, hospital, lab, or other provider. You usually:

• Show your insurance card
• Pay a copay (if your plan has one)

2. The provider creates and submits the claim

The provider:

• Lists your diagnosis (why you were treated)
• Lists services or procedures (what was done)
• Assigns codes (standardized medical codes)
• Sends the claim to your insurance plan with the total charges

3. Your insurance reviews the claim (called “adjudication”)

The insurance company:

• Checks if you were covered on the service date
• Confirms whether the service is covered by your plan
• Applies your deductible, copays, and coinsurance
• Checks if the provider is in-network or out-of-network
• Reduces the charges to the allowed amount (what they consider reasonable under your plan contract)

4. Payment is made

Depending on your plan and situation:

• The insurer pays the provider directly for its share.
• The provider then bills you for your remaining share.
• If you paid up front and filed yourself, the insurer may reimburse you.

5. You receive an Explanation of Benefits (EOB)

An Explanation of Benefits (EOB) is not a bill. It’s a summary your health insurance company sends that shows:

• What service you received
• What the provider charged
• What the plan’s allowed amount is
• How much the plan paid
• How much you may owe the provider

Claim vs. Bill vs. EOB: What’s the Difference?

These three can be easy to mix up, but they serve different purposes.

A health insurance claim is about insurance and payment.
A medical bill is about what you owe.
An EOB bridges the two, explaining how the claim led to that bill.

Types of Health Insurance Claims

Not all claims look the same. Some common types include:

1. In-network claims

• Provider is in your plan’s network.
• Claims are usually filed automatically by the provider.
• You often pay lower costs because the provider has a contract with your plan.

2. Out-of-network claims

• Provider is not in your plan’s network.
• Coverage may be partial, more limited, or sometimes not included, depending on your policy.
• You may need to file the claim yourself and pay a larger share.

3. Pharmacy / prescription drug claims

• Usually processed at the pharmacy counter when you present your insurance card.
• You often pay a copay or coinsurance, and the rest is billed directly to your plan.
• For some medications purchased out of network or during travel, you might submit a claim for reimbursement.

4. Emergency or urgent care claims

• Emergency services often have special protections in many plans, especially if you needed immediate care.
• Claims for emergencies may be handled differently from routine out-of-network visits, but you may still see higher costs if out-of-network rules apply.

Why Some Claims Are Denied

A claim denial happens when your health insurance company decides not to pay for some or all of a service.

Common reasons claims may be denied include:

• The service is not covered by your plan.
• The provider is out-of-network and your plan has limited or no out-of-network coverage.
• The claim was submitted too late according to plan deadlines.
• The information on the claim was incomplete or incorrect (wrong code, missing details, mismatched patient info).
• The service is considered not medically necessary under your plan’s rules.

A denial does not always mean the decision is final. Many plans allow you to appeal the decision.

How to Read and Understand an EOB

Your Explanation of Benefits is one of the most useful tools for understanding claims.

An EOB typically includes:

• Patient name and date of service
• Provider’s name
• Type of service (office visit, lab test, imaging, etc.)
• Amount the provider billed
• Allowed amount (what the plan considers reasonable to pay on)
• Amount applied to your deductible
• Any copay or coinsurance
• Amount the plan paid
• Amount you may owe the provider

📝 Helpful habit: Compare your EOB with the bill from your provider. The amount you’re being asked to pay should match what the EOB says is “your responsibility.” If it doesn’t, you can call the provider or your insurer for clarification.

What To Do If There’s an Error on a Claim

Errors can happen, and they can affect how much you owe.

If something on your EOB or bill doesn’t look right:

1. Check details carefully

   • Dates of service
   • Provider name
   • Type of service
   • Amounts charged

2. Call your provider’s billing office

   • Ask them to explain the charge.
   • Confirm that they sent the claim with the correct codes and insurance information.

3. Call your insurance company

   • Ask how they processed the claim.
   • Request a review if you believe something was misapplied (for example, not counted toward your deductible or out-of-pocket maximum).

4. Request a corrected claim if needed

   • Providers can often resubmit claims with corrections.

How to Appeal a Denied Claim

If a claim is denied and you believe it should be covered:

1. Read the denial notice

   • It should explain why the claim was denied.

2. Gather documents

   • EOB
   • Bills
   • Any supporting notes or letters from your provider (if applicable).

3. Follow your plan’s appeal steps

   • Most plans outline a formal appeals process with deadlines.
   • You may need to send a written appeal form and supporting documents.

4. Keep records

   • Save copies of all letters, forms, and notes from phone calls.

Appeals can take time, but many consumers find that errors or misunderstandings are corrected once they provide more information.

How Health Insurance Claims Affect Your Costs

Every processed claim changes where you stand with key parts of your plan:

• Deductible – Claims help move you toward meeting your annual deductible.
• Out-of-pocket maximum – Payments you make toward covered services count toward this limit.
• Future costs – Once your deductible is met, your plan may pay a larger share of future claims in that same year.

This is why it’s useful to track:

• How much of your deductible you’ve met
• How close you are to your out-of-pocket maximum
• Whether your claims are being processed as in-network or out-of-network

Tips for Smoother Claim Experiences

You can’t control everything in the health insurance system, but a few steps can reduce surprises:

• Carry and show your insurance card at every visit.
• Confirm network status before non-emergency appointments:
  • Ask if the provider and the facility are in-network for your specific plan.
• Ask for an itemized bill from providers, especially for larger services or hospital stays.
• Keep copies of receipts, bills, and any claim forms you submit.
• Review your EOBs promptly so you can catch errors early.
• Know your plan basics: deductible, copays, coinsurance, and out-of-pocket maximum.

Quick Reference: Health Insurance Claim at a Glance

• A health insurance claim is a request for payment sent to your insurer for medical care you received.
• Most claims are filed by your healthcare provider directly.
• Your insurer reviews the claim and decides how much it will pay based on your coverage.
• You receive an Explanation of Benefits (EOB) explaining what was billed, what the insurer paid, and what you may still owe.
• You then may receive a bill from your provider for your share of the costs.
• If a claim is denied or seems incorrect, you can ask questions, request corrections, and file an appeal if needed.

Once you understand what a health insurance claim is and how it works, your bills, EOBs, and coverage details become much clearer, and you can navigate your health insurance with more confidence.