The health insurance claims process is how your doctor gets paid after a visit. First, the provider sends a claim to your plan. Next, the plan checks it, applies your benefits and sends you an Explanation of Benefits (EOB). Then the provider bills you for your share. So for most in-network care, your only job is to check the EOB.
- In-network providers usually file the claim for you, while out-of-network care may mean you file it yourself.
- An EOB is not a bill, and your provider's bill should not be higher than the patient balance on it.
- HealthCare.gov insurers denied 19% of in-network claims in 2024, yet people appealed fewer than 1% of those denials.
- You have 180 days after a denial to file an internal appeal, and an external reviewer's decision binds the insurer.
- The No Surprises Act blocks most surprise bills for emergency care and for outside doctors at in-network facilities.
What is the health insurance claims process?
A claim is a bill your doctor sends to your health plan instead of to you. Also, it lists each service you got, a medical code for each one, and the price. Your plan then decides how much to pay, based on your benefits.
So every claim settles two things at once: what your plan pays and what you owe. As a result, it's worth five minutes after each visit. For example, our guide on how medical billing works behind the scenes explains the codes and charges.
Never pay a medical bill until you match it to your EOB.The habit that saves our clients the most money
Who files the claim: you or your doctor?
It depends on whether your provider is in your plan's network, so here is how the two paths compare.
- The provider files the claim for you
- You show your ID card and pay any copay first
- Network contracts generally bar billing above the allowed amount
- Then you pay the rest after the EOB arrives
- You may also have to file the claim yourself
- The office may ask you to pay in full up front
- Your plan may pay less, or nothing at all
- The provider can bill you the difference unless federal protections apply
First, ask the provider for an itemized bill when you file your own claim. Then get your plan's claim form from the member website or the number on your ID card. Plans set their own filing deadlines, so check yours in your plan documents. Also, our guide to reading every line of your ID card shows where to find those contacts.
Before you book care outside your network, read our breakdown of what out-of-network care really costs.
The 7 steps of the health insurance claims process
Most claims move through the same seven steps. In most cases, electronic claims finish within a few weeks.
- You get care.
Show your current ID card. Then the office checks your coverage and collects any copay.
- Your provider sends the claim.
Its billing team codes each service and then sends the claim, usually online.
- The plan confirms your coverage.
Next, it checks that your plan was active on the date of care and that you paid your premium.
- The plan reviews the details.
It also checks the codes, the network status and any required approval.
- Your benefits kick in.
First the plan applies the network discount, then your deductible, copay or coinsurance.
- You get an EOB.
It shows the billed amount, the allowed amount, what the plan paid and what you may owe.
- The provider bills you.
Compare that bill to your EOB before you pay a cent.
Those federal deadlines apply when a plan denies a claim. So to follow a claim in real time, see how to track where your claim stands. Also, our guide to how long each claim step takes explains normal delays.
How to read your EOB
According to CMS, an EOB isn't a bill. Instead, it shows what your plan paid and what you will likely owe. For example, here is a sample EOB for an in-network MRI, with made-up numbers to show the math.
| EOB line and what it means | Example |
|---|---|
| Billed amount: the provider's full price | $2,000 |
| Allowed amount: the price your plan agreed to pay this provider | $900 |
| Applied to deductible: the part you pay before the plan shares costs | $500 |
| Coinsurance (20%): your share of the remaining $400 | $80 |
| Plan paid: what your plan sends the provider | $320 |
| Patient balance: your total for this claim | $580 |
In this case, a $2,000 MRI costs you $580. Meanwhile, the network discount wipes out the other $1,100. If the bill says more than $580, call the billing office before you pay. To see how each piece works, also read about how your deductible resets and fills and copays and coinsurance explained.
Also, what you pay for covered in-network care counts toward your yearly cap. Our guide to your out-of-pocket maximum shows when you stop paying.
Look for the small remark codes on your EOB, since CMS notes their meanings print at the bottom of the page. Also, keep every EOB until the plan year ends and every bill is settled, because you may need them for a dispute or an appeal.
A licensed Vivna agent can walk you through it line by line and also help you pick a plan with fewer surprises, at no cost to you.
Prior authorization: approval before care
Some services need your plan's approval before you get them. Insurers call this step prior authorization. In most cases, your doctor's office sends the request. If you skip it, your plan can deny the claim even when it would normally cover the care.
Prior authorization often happens before the health insurance claims process even starts. In fact, KFF found that missing prior authorization or referrals made up 9% of in-network denial reasons in 2024. So before any planned test or surgery, ask these questions.
- Does this service need prior authorization under my plan?
- Has my plan approved it, and what is the approval number?
- Also, which dates and which facility does the approval cover?
- Are the surgeon, the facility and the lab in my network too?
Why health insurance claims get denied
Denials happen more often than most people think. For example, KFF studied in-network claims for insurers on HealthCare.gov in 2024, and here is what it found.
Denial rates also varied widely, from about 3% to 36% across insurers. Below are the top named reasons KFF tracked, while another 36% fell under other reasons.
Administrative errors lead the list, so watch for these common slip-ups.
- A wrong member ID, name or date of birth on the claim
- Coding mistakes or missing codes
- A claim sent to an old plan after you switched
- The same service billed twice, such as after a hospital stay
- In-network care processed as out-of-network
For any of these, call the provider's billing office first. They can often send a corrected claim, so you may not need an appeal. If your plan keeps causing trouble, our guide to fixing common health plan problems can help.
How to appeal a denied claim
A denial is not the final word. In fact, federal rules give you two levels of review. Yet so few people appeal that most denials simply stand.
Step 1: Internal appeal
First, you ask your plan to review its own decision. You must file within 180 days of the denial notice. Your plan then has 30 days to decide for care you haven't received yet, or 60 days for care you already got. However, urgent cases can use a faster, expedited appeal.
Step 2: External review
If your plan still says no, an independent reviewer can look at the case. Next, you must ask in writing within 4 months of the final denial. A standard review ends within 45 days, while an expedited review ends within 72 hours. In the end, your insurer must accept the reviewer's decision.
The federal process costs nothing, while a state or private reviewer can't charge more than $25.
Deadlines matter, because missing the 180-day internal appeal window can cost you the right to challenge the denial. So mark the date on your calendar the day the notice arrives.
A strong appeal includes these items:
- The denial letter and the EOB
- A letter from your doctor that explains why you need the care
- Medical records that support your case
- A short note in your own words
- Copies of everything, plus notes from each phone call
For sample wording and a full checklist, see how to write a strong appeal letter.
Surprise bills and the No Surprises Act
Sometimes the claim is fine, but the bill still shocks you. The good news is that the federal No Surprises Act stops many of those bills. For example, it protects you in these cases.
- Emergency care: out-of-network providers can't bill more than your in-network cost sharing.
- Outside doctors at in-network hospitals: surprise bills for most non-emergency care are generally banned.
- Air ambulance: surprise bills for covered air ambulance trips are generally banned.
- Uninsured or self-pay: you may also dispute a bill that runs at least $400 over your good faith estimate.
If you get a bill you think breaks these rules, call the No Surprises Help Desk at 1-800-985-3059. You can also call a licensed Vivna agent at 888-730-6001 to talk through your next step.
Make the health insurance claims process easier
A few habits prevent most claim headaches, so pick the card that fits your situation right now.
Confirm prior authorization and the network status of every provider before the date.
Match it to the EOB, then ask the office for an itemized bill.
Call billing first, then file an internal appeal within 180 days.
Then compare new plans at Open Enrollment with a licensed agent.
So if your current plan has a narrow network or confusing rules, it may be time to compare individual health insurance plans. You can also browse our health insurance FAQ library or start with our beginner's guide to how coverage works.
Health insurance claims process: FAQs
How long does a health insurance claim take?
In most cases, clean electronic claims finish within a few weeks. Under federal rules, a plan generally has up to 30 days to decide on care you already received. For prior authorization requests, the limit is 15 days, while urgent care claims get 72 hours. Claims with missing information take longer, because the plan has to ask the provider for more details.
Do I have to file my own medical insurance claims?
Usually not. Instead, in-network doctors, hospitals and labs file medical insurance claims for you. However, you may need to file yourself after out-of-network care, especially if you paid the bill up front. In that case, get an itemized bill, fill out your plan's claim form and send both before your plan's filing deadline. Also keep copies of everything you send.
Is an EOB the same as a bill?
No. An Explanation of Benefits shows what the provider charged, what your plan allowed and paid, and what you may owe. Your provider sends the actual bill later. According to CMS, that bill should not be higher than the patient balance on your EOB. If it is, call the provider's billing office before you pay.
What should I do if my claim is denied?
First, read the denial reason on the EOB or the denial letter. Next, call the provider's billing office, because many denials come from simple errors they can correct. If the denial still stands, file an internal appeal within 180 days. If your plan says no again, you can then request an external review within 4 months.
Can an insurance agent help with health insurance claims?
Yes. A licensed agent can explain your EOB, help you find the right contacts at your plan and walk you through an appeal. An agent can also help you choose a plan whose network and rules fit how you use care. That step can prevent many claim problems before they start. Plus, Vivna's help comes at no cost to you.
Vivna's licensed agents compare plans from 50+ carriers. Call Monday through Friday, 9am to 6pm.
Sources
- HealthCare.gov: Internal appeals
- HealthCare.gov: External review
- CMS: How to read an explanation of benefits
- KFF: Claims denials and appeals in ACA Marketplace plans in 2024
- CMS: No Surprises Act overview of key consumer protections
Vivna Insurance is a licensed, independent health insurance agency (NPN 19168641). We are not affiliated with HealthCare.gov or any government agency. Plan availability, networks and benefits vary by state and change over time.