For Consumers

How your 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 are the deductible, copay or coinsurance amounts, and when do you need to pay them?
  • Do you need a referral or pre-authorization before you can get treatment?

Talk to your medical provider

  • Confirm with both your health plan and medical 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 first and then wait for your health plan to reimburse you. If possible, ask your health plan about this process before you pay your medical provider.
  • There are certain situations in which an out-of-network provider must bill your plan directly and not bill you more than your cost shares. Learn more about balance billing.

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 the problem, file an appeal with your health plan
  • Keep track of appeal due dates.

You can also file a complaint with our office. Filing a complaint will not replace your appeal rights with your health plan.