How do health insurance claims work?

1. Medical care provider files claim:

- When you receive medical care from a healthcare professional, they submit a claim to your health insurance company.

- This claim includes details about the services provided, the date of service, and the cost.

2. Insurance company reviews claim:

- The insurance company reviews the claim to ensure it meets all the requirements for coverage.

- They may verify that you were eligible for coverage and that the services provided were covered by your health plan.

3. Insurance company processes claim:

- Once the claim is approved, the insurance company processes it by:

1) Determining the amount of coverage they will provide based on your plan.

2) Paying the healthcare provider directly or reimbursing you for any out-of-pocket expenses you have paid.

4. You may be responsible for copays, coinsurance, or deductibles:

- Depending on your health insurance plan, you may have to pay a copay (a fixed dollar amount) or a coinsurance (a percentage of the total cost) for certain services.

- You may also have an annual deductible, which is a set dollar amount that you have to pay out of pocket before your insurance starts covering costs.

5. You may receive an explanation of benefits (EOB):

- After your claim has been processed, you may receive an explanation of benefits (EOB) from your insurance company.

- This document provides details about the services that were covered, the amount you're responsible for, and any payments made by the insurance company.

It's essential to understand how health insurance claims work to navigate your healthcare costs and ensure that you receive the coverage you're entitled to. If you have any questions or concerns about a claim, it's best to contact your health insurance company for assistance.