What Is a Health Insurance Claim?

A health insurance claim is essentially a notification sent to an insurance company that a policyholder has received medical services or treatments that should be covered under their health insurance plan.

When the claim is filed, the insurance company verifies and ensures that the services received are included under the policy's scope of coverage and determines the amount of reimbursement or payment due to the health care provider or the insured individual. The purpose of a claim is to formalize the request for insurance benefits based on the policy agreement.

In health insurance, a “claim” is a formal request by an insured individual or health care provider to an insurance company for payment of services rendered, as per the insurance policy. It includes necessary information such as the insured's policy number, details of the medical services, date of service and costs involved.

The insurance company evaluates the claim against the insured's policy coverage upon submission. The outcome is communicated through an Explanation of Benefits (EOB), which details the services covered, payments made and any financial responsibility of the insured. The EOB serves to clarify the coverage applied and any costs the insured must bear. A claim bridges health care services received and the financial aspects of insurance coverage.

There are primarily three types of health insurance claims: direct billing (cashless) claims, reimbursement claims and pre-authorization claims. Each type is different in how a policyholder accesses and pays for medical care.

These claims occur when a policyholder receives medical services from a network provider, and the bill is sent directly to the insurance company. The insurer settles the bill with the provider, barring any copayment or deductible that the policyholder is responsible for. This type is advantageous in emergencies or planned hospitalizations, as the insured does not have to make upfront payments.

In this scenario, the policyholder pays for the medical services out-of-pocket and then submits a claim to the insurance company for reimbursement. This claim type is common when services are rendered by a provider outside the insurance network or in cases where a cashless facility is unavailable. The policyholder must submit all relevant bills and documents to the insurer, who, after verification, reimburse the covered amount.

Often required for planned hospitalization or expensive treatments, pre-authorization claims involve seeking prior approval from the insurance company before undergoing medical procedures. The health care provider or the insured submits a request detailing the proposed treatment and estimated costs. The insurer reviews this request and determines eligibility based on the policy's coverage. Pre-authorization ensures that the insurer will cover the costs.

To file a health insurance claim, first verify your policy coverage. Collect all necessary medical documents and receipts. Fill out your insurer's claim form with accurate details. Submit the form along with supporting documents to your insurance provider. Keep track of your claim's status and retain copies for your records.

We have given some answers below to common questions you may have about health insurance claims.