A claim is the bill your doctor, hospital, or other health care provider sends to your insurance company after you receive care. It's how your provider asks your plan to pay its share of the cost.
In most cases, you don't need to file a claim yourself. When you see an in-network provider, they submit the claim directly to your insurance company. The insurer reviews the claim, determines how much is covered based on your plan, pays the provider their portion, and sends you an Explanation of Benefits (EOB) showing the breakdown.
You might need to file a claim on your own if you saw an out-of-network provider who doesn't bill your insurer directly, or if you received care while traveling. To file, you typically submit a claim form along with an itemized bill from the provider.
After your insurer processes a claim, you'll receive an EOB; this is not a bill. It shows what was billed, what the plan paid, and what you owe (your copay, coinsurance, or deductible portion). Your actual bill comes separately from the provider.
If a claim is denied, you have the right to appeal the decision. Your insurer must explain why a claim was denied and tell you how to request a review.
Most states require insurers to process claims within 30–45 days. If your claim takes longer, contact your insurer to check its status, and keep records of all communications.
Start by reading your Explanation of Benefits to understand why. Common reasons include missing information, coding errors, or the service not being covered. You can call your insurer to resolve simple issues or file a formal appeal if you believe the denial was wrong.
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