What Is a Health Insurance Claim?
A health insurance claim is a formal request for payment submitted to your insurance company after you receive healthcare services. In most cases, your healthcare provider submits the claim directly to your insurer — you don't have to do anything.
How the Claims Process Works
- You receive care from a healthcare provider
- Your provider submits a claim to your insurer with medical codes describing the services
- Your insurer processes the claim, applying your deductible, copay, and coinsurance
- Your insurer pays the provider the allowed amount minus your cost-sharing
- You receive an Explanation of Benefits (EOB) showing how the claim was processed
- Your provider bills you for your portion (copay, deductible, coinsurance)
💡 Always compare the EOB from your insurer with the bill from your provider. They should match. If they don't, contact your insurer before paying.
What Is a Claim Denial?
A claim denial means your insurer refused to pay for all or part of the service. Common reasons include: service not covered, prior authorization not obtained, out-of-network provider, or incorrect billing codes. You have the right to appeal any denial.
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