What's a Health Insurance Claim?

what is claim in insurance

By Elizabeth Davis, RN. Health Insurance Expert

As a Registered Nurse and freelance medical writer, Elizabeth has been helping people navigate the complexities of their health insurance and the healthcare system for more than 25 years.

Updated March 07, 2014.

Most health plans have a paper or online form to use when filing a claim. To fill out the claim form and file the claim, you’ll need information like the doctor or health care provider’s name and address, the date you got the care, and the insurance codes used to define your diagnosis and what kind of service your doctor provided.

Although you may file the claim yourself, your doctor or health care provider will often file the claim for you. This is most common when you use in-network providers. If you use an out-of-network provider, the provider might file the

claim for you, but they might not. You’ll have to ask.

If your out-of-network provider doesn’t file the claim, you’ll have to do so. Make sure to ask him or her for the appropriate insurance codes.

Your insurer might also want the provider’s tax identification number.

Sometimes health insurance companies will ask for more information to complete the processing of the claim. Don’t be freaked out if this happens. It doesn’t necessarily mean something is wrong; a request for more information is fairly common.

After your health plan finishes processing the claim, it’ll send you an explanation of benefits. The EOB will show you what services the claim was for, how much the bill was, what the insurance company paid, and how much you’ll be required to pay in the form of deductible, copay, or coinsurance for this particular claim.

Source: healthinsurance.about.com

Category: Insurance

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