Updated: September 10, 2025
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Choosing in-network providers simplifies claims through direct billing. The providers handle paperwork while you pay only your copay or deductible.
Three main types of health insurance claims work in different ways: direct billing claims, reimbursement claims and pre-authorization claims.
Accurate documentation speeds claim approval. Include itemized bills with correct medical codes and detailed reports for faster processing.
In health insurance, a claim is a formal request you or your health care provider submits to an insurance company for payment of services rendered under your insurance policy. A health insurance claim includes necessary information such as your policy number, details of the medical services, date of service and costs involved.
Most claims are filed electronically by your doctor's office, but you may need to file health insurance claims yourself when seeing out-of-network providers.
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.
Type of Claim | Definition | Terms and Speed of Claim | Example of Each Claim Type | Additional Pointers |
|---|---|---|---|---|
Direct Billing (Cashless) Claims | Your provider submits claims directly to your insurer. At the visit, you pay only copays, coinsurance or deductible amounts. | Most states require insurers to process error-free claims within 30-45 days. You'll receive an EOB showing what your insurer paid and your balance. Processing times and requirements vary by state and insurer. Verify your specific policy terms. | You pay a $25 copay at your doctor's office. They handle the claim submission and receive the remaining $150 directly. | This works best with in-network providers for routine services, minimizing upfront costs. |
Reimbursement Claims | You pay providers upfront, then submit receipts to your insurer to reimburse covered expenses. | Submit claims within your policy's deadline, typically 12 months from the service date. Processing takes 30-60 days, depending on state laws. | You pay $400 upfront for an out-of-state specialist. Your insurer reimburses $320 (80% coverage), leaving you responsible for $80. | This applies to out-of-network providers or when cashless facilities aren't available. |
Pre-Authorization Claims | Your doctor requests insurer approval before providing specific treatments, preventing denials and confirming coverage upfront. | Health insurers must respond within 30 business days for non-urgent requests. Urgent conditions receive expedited review. | Your orthopedist requests pre-authorization for a knee MRI from your insurer, submitting medical records proving the necessity before scheduling. | Get pre-authorization for MRIs, CT scans, specialty medications and elective surgeries to avoid unexpected bills. |
Emergency Care Protections:
Under the No Surprises Act and CMS regulations, emergency room visits can't cost more than in-network rates, even at out-of-network hospitals. Emergency services cannot require pre-authorization. Emergency care is covered when you reasonably believe it's an emergency.
Coordination of Benefits:
When you are covered by two or more health insurance plans coordination of benefits determines which pays first (primary) and second (secondary). Your employer's plan is typically primary over your spouse's plan. Submit claims to your primary insurer first, then the remaining balances to the secondary insurer with the primary EOB (your coverage summary).
The "birthday rule" applies to children: the parent with the earlier birthday has the primary plan. Combined payments won't exceed 100% of your costs but will reduce your out-of-pocket expenses.
To file a health insurance claim, verify your policy coverage, collect necessary documentation and submit within your policy's time limit. Submit claims within 12 months for Medicare or 180 days to one year for private insurance. Keep copies of all documents for your records and potential appeals.
File a health insurance claim through these steps:
Before any medical procedure, confirm with your health insurance provider what your policy covers, including out-of-pocket expenses, deductibles and coinsurance. Verify if your procedure requires pre-authorization or your provider is in-network. Call your insurer to verify coverage and ask providers for treatment codes (CPT) to get accurate cost estimates.
After receiving services, request an itemized bill from your health care provider detailing every service, treatment, medication and their costs. Make sure the bill includes accurate medical codes: CPT codes describe procedures performed, while ICD-10 codes describe your diagnosis.
Get a claim form from your insurance provider online or through direct contact. You'll need the Patient Request for Medical Payment form (CMS-1490S) for Medicare claims. Complete the form accurately with detailed information about the medical service, costs and your policy number.
Submit the completed claim form with all required documentation. Submit electronically through your insurer's portal for fastest processing, or via mail if online submission isn't available. You must file Medicare claims within 12 months (or one full calendar year) after the service date.
Monitor your claim status through your insurer's system. Most insurers process claims within 30 days, though processing times vary. Mark the expected decision date on your calendar and follow up if you haven't received feedback within their stated timeframe.
The insurance company reviews your claim to verify coverage and assess the documents provided. This process, known as claim adjudication, includes verifying medical necessity and policy compliance. Processing times vary depending on claim complexity and the insurer's procedures.
The insurer will inform you whether the claim is approved or denied. If approved, payment depends on your policy terms: either the provider receives direct payment or you receive reimbursement. You'll receive an Explanation of Benefits (EOB) detailing how the insurer processed your claim, including what was covered, what you owe and any payments made to providers.
If your insurer denies your claim or you're unsatisfied with the settlement, review the health insurance claim appeal process outlined in your policy. You may need to provide additional information and supporting documentation or correct any errors in the initial claim.
After resolving any disputes, make your final payment. Maintain organized files of all claims and related documents for future reference. These records help you track health care expenses, manage future appeals and prepare tax returns.
If your health insurance claim is denied, you can appeal the decision. Most denials come from fixable issues like coding errors or missing paperwork.
Read the denial letter to understand the specific reason for denial. Contact your doctor's office first before proceeding to the next step.
Gather supporting documentation, such as medical records from your treatment, doctor's notes explaining medical necessity and test results supporting your claim appeal.
Write a clear appeal letter explaining why you need the treatment and include your doctor's supporting documentation. File your internal appeal within 180 days from the denial date.
Most insurers must respond to appeals within these timeframes:
Ask for an external review if your internal appeal fails. An independent third party will review and decide your claim appeal.
Health insurance claims connect you to the financial protection you've already paid for. Three filing methods determine how you pay and get reimbursed: direct billing for routine in-network visits, reimbursement claims for out-of-network flexibility and pre-authorization for expensive procedures.
Filing before deadlines and completing paperwork correctly prevent most denials. Claims get rejected when you skip pre-authorization for expensive procedures, accidentally use out-of-network doctors or submit missing information. Getting pre-approval for MRIs and specialty treatments stops costly surprises, and proper medical codes on your bills help insurers make accurate coverage decisions.
We answer common questions about health insurance claims:
If your insurer denies your health insurance claim, read your Explanation of Benefits to understand why. Collect paperwork from your provider, fix mistakes on the claim and add medical records that prove necessity. If codes or details are unclear, call your provider for clarity. Review everything before resubmitting. You have up to 180 days to file an internal appeal with your insurer.
Health insurance claims can be filed by either the health care provider (direct billing) or you (reimbursement model). In direct billing, the provider submits the claim to your insurer and receives payment while you pay only your copay or deductible. With reimbursement claims, you pay the bill upfront and then send receipts to get reimbursed.
Health insurance claims can be filed online through the insurer's portal for convenience and speed, or mailed physically. Some insurers also allow submitting claims via phone or mobile apps, though these may require extra follow-up. For Medicare claims, use the Patient Request for Medical Payment form (CMS-1490S).
To file a health insurance claim, you need your insurance policy number, itemized bills from your provider and all medical records related to your treatment. Ask your provider for bills that show the correct medical codes. Include receipts, prescriptions, reports and any notes from your provider. If you see a specialist, add referral notes and verify that all dates, provider details and services are accurate.
Missing the deadline to file a health insurance claim usually means the insurer will deny the claim, and you'll cover those costs yourself. For Medicare, you must file within 12 months of the service date. Most private insurers give you 180 days to one year, depending on your plan. If you miss the deadline, call your insurer immediately and ask about exceptions.
About Mark Fitzpatrick
Mark Fitzpatrick, a Licensed Property and Casualty Insurance Producer, is MoneyGeek's resident Personal Finance Expert. With over five years of experience analyzing the insurance market, he conducts original research and creates tailored content for all types of buyers. His insights have been featured in publications like CNBC, NBC News and Mashable.
Fitzpatrick holds a master’s degree in economics and international relations from Johns Hopkins University and a bachelor’s degree from Boston College. He's also a five-time Jeopardy champion!
Passionate about economics and insurance, he aims to promote transparency in financial topics and empower others to make confident money decisions.
