What Is a Health Insurance Claim?
When you visit a doctor or hospital, the provider submits a claim to your insurance company requesting payment for the services they performed. The insurance company reviews the claim, determines how much is covered under your plan, pays their portion, and sends you an Explanation of Benefits (EOB) showing the breakdown.
How the Claims Process Works
- You receive medical care
- The provider submits a claim to your insurance (usually electronic)
- Your insurance processes the claim against your plan benefits
- Insurance pays the provider their portion (if in-network)
- You receive an EOB showing what you owe
- The provider sends you a bill for your portion (copay, coinsurance, deductible)
Common Reasons Claims Get Denied
- Service required prior authorization that wasn't obtained
- Provider was out-of-network
- Service not covered under your plan
- Billing error or incorrect coding
- Duplicate claim submission
If a claim is denied: You have the right to appeal. Most denials are overturned on appeal — especially when the denial was due to a coding error or missing documentation. Start with your insurance company's internal appeal process. If that fails, you can request an external review by an independent third party.
Related Terms
Last updated: March 30, 2026.
