How to File a Health Insurance Claim

Most health insurance claims are filed by your provider. But understanding the process helps you catch errors, know your rights, and navigate denials when they happen.

When You Need to File a Claim

You may need to file yourself when:

• You received out-of-network care
• Your provider doesn’t accept your insurance
• You received care while traveling
• You paid upfront and need reimbursement
• Your provider failed to submit a claim

Understanding Your Benefits

Key Terms

In-Network vs. Out-of-Network

How to File a Claim

Step 1: Get an Itemized Bill

Request from your provider:

• Date of service
• Procedure codes (CPT codes)
• Diagnosis codes (ICD-10)
• Provider’s name and NPI number
• Amount charged

Step 2: Complete a Claim Form

Obtain your insurer’s claim form (usually on their website). Include:

• Your member ID and group number
• Patient information
• Provider information
• Service details from the itemized bill
• Explanation of why you’re filing (out-of-network, emergency, etc.)

Step 3: Submit with Documentation

Include:

• Completed claim form
• Itemized bill
• Proof of payment (if you paid upfront)
• Any supporting documentation

Submit via:

• Online portal (fastest)
• Mobile app
• Mail to claims address on your insurance card
• Fax (keep confirmation)

Step 4: Track Your Claim

• Note the claim number
• Check status online or by phone
• Expect processing in 2-4 weeks
• Review the EOB when it arrives

Reading Your EOB

An Explanation of Benefits shows:

1. Service details - What was provided and when
2. Amount billed - What the provider charged
3. Allowed amount - What your insurer considers reasonable
4. Plan payment - What insurance paid
5. Your responsibility - What you owe (deductible, copay, coinsurance)
6. Notes/codes - Explanations for adjustments or denials

Common EOB issues:

• Service denied (may need appeal)
• Applied to deductible (you pay full amount until deductible met)
• Balance billing (out-of-network provider billing difference)

Pre-Authorization

Some services require advance approval:

Typically Requires Pre-Authorization

• Hospital admissions (non-emergency)
• Surgeries
• Advanced imaging (MRI, CT)
• Specialty medications
• Durable medical equipment
• Mental health treatment (extended)

How It Works

1. Provider submits request to insurer
2. Insurer reviews medical necessity
3. Approval, denial, or request for more info
4. You proceed with approved care

Tip: Get pre-authorization in writing. Emergency care doesn’t require prior approval.

Appealing a Denied Claim

Common Denial Reasons

• Service not covered
• Pre-authorization not obtained
• Out-of-network provider
• Coding errors
• Not medically necessary
• Duplicate claim

The Appeals Process

Step 1: Understand the denial

• Request written explanation
• Review your policy’s coverage
• Check for errors in the claim

Step 2: Internal appeal

• File within deadline (usually 180 days)
• Include supporting documentation:
  • Letter explaining why coverage should apply
  • Doctor’s letter of medical necessity
  • Relevant medical records
  • Policy sections supporting your case

Step 3: External review

• If internal appeal denied, request external review
• Independent third party reviews your case
• Decision is usually binding on the insurer

Appeal Letter Tips

• Reference specific policy language
• Include claim number and dates
• Be factual and professional
• Attach supporting medical documentation
• Keep copies of everything

Documentation Checklist

When Filing a Claim

• Itemized bill with procedure codes
• Completed claim form
• Proof of payment (receipt, credit card statement)
• Provider’s NPI number
• Your member ID card copy

When Appealing a Denial

• Denial letter with reason codes
• Your policy’s coverage language
• Doctor’s letter of medical necessity
• Relevant medical records
• Timeline of care and communications

Tips for Managing Health Claims

1. Keep all EOBs - Compare to provider bills
2. Check for errors - Coding mistakes are common
3. Know your benefits - Understand what’s covered
4. Use in-network providers - Lower costs, fewer hassles
5. Get pre-authorization - Don’t skip required approvals
6. Appeal denials - Many are reversed on appeal
7. Track your spending - Know when you’ve hit your deductible and out-of-pocket max

Related Guides

• Health Insurance Guide
• HMO vs PPO Explained
• Insurance FAQ
• Insurance Glossary