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How the health insurance claims process works

Understanding the process can help save you time and avoid frustration.

Know your health plan

• Does your health plan have network providers?
• Does your health plan allow for out-of-network providers?
• What's the deductible, copay or coinsurance amounts, and when do you need to pay them?

Talk to your medical provider

• Confirm with both your health plan and provider that they're part of your plan's network.
• Ask your medical provider how they collect your deductible, copay and coinsurance, and how they bill for services. 
  • Network providers bill the health plan directly.
  • Out-of-network providers don't have to bill the health plan, so you may need to do it.

Review your bill and the Explanation of Benefits (EOB)

• Network providers - Compare your bill with the EOB and pay what the health plan states is your responsibility to the medical provider.
• Out-of-network providers - Contact your health plan to get claim forms and due dates.  You may have to pay the medical provider and wait for your health plan to reimburse you. If possible, ask your health plan about this process before you pay the medical provider.

Claim problems or disputes

• Review the coverage, benefits, and appeals sections of your health plan contract.
• Contact the health plan and medical provider and attempt to resolve your claim informally.
• If you can't resolve it, file an appeal with your health plan. 
• Keep track of appeal due dates.
• Need more help?  Call us at 800-562-6900 or read our appeals guide for help and tips.
• Want to file a complaint against the health plan?

Updated 04/10/2012