Guide to Medical Claims Process

Medical Claims Process – Overview

Medical insurance systems can seem quite complex, especially if you do not work in the field. However, it is crucial to learn the steps of the medical claims process, so you know what to expect and how to manage any issue that arises.

What Is a Medical Claim?

A medical claim is a request for payment from your healthcare provider to your insurance provider. This claim details the diagnoses, tests, and treatments provided to you. This claim ensures that the doctor gets paid the medical expenses through your insurance benefits coverage, and the patient bears the balance amount.

A medical claim is often initiated after services are rendered, not just when a patient checks into a healthcare facility. This claim covers the services rendered during the patient’s visit, culminating in the issuance of the final bill.

Patients may need to file claims themselves when visiting out-of-network doctors, depending on their insurance policy. Generally, claims are automatically submitted to the insurance company from the healthcare provider once an appointment or service is rendered to a patient.

In addition, the claims processing centers adhere to strict HIPAA guidelines and ensure the security and safety of patients’ sensitive medical data.

Medical Claims Process

Medical Claims Process – How to File a Medical Claim?

How to File a Medical Claim?

Healthcare providers within the insurance provider’s network usually send medical claims themselves. Once a health care service has been provided, the healthcare provider will prepare the claim using the patient’s information and any required documentation from the visit.

This will also include medical codes sent to the claims processing department or a third-party administrator.

The medical claim form undergoes a review and adjudication process by the insurance company. The insurance company will cover eligible expenses according to the patient’s specific coverage plan. If any balance amount remains to be paid, the patient will be sent a bill for this, while the doctor will get paid directly for the service rendered.

However, if you get treatment from a healthcare provider who is not within the insurance network, then it is likely that you will have to file the medical claim yourself.

Here are the simple steps for the medical claims process:

1. First, make sure to select the correct claim form that is in line with your insurance plan. Then, you can simply log in to your insurance provider’s official website with your credentials and find the relevant claims form according to the specific healthcare condition you are experiencing.

2. If you fill out the medical claims form by hand, make sure to do so in a legible and readable way and fill in the details accurately. On the other hand, you can also choose to fill out a medical claims form online at your insurance provider’s official website.

3. While filling out the medical claims form, include all relevant information, including the date of service and any medical codes provided by your doctor’s office.

4. Check the time limit for submitting medical claims after service, and make sure to submit your claims application before the designated deadline.

5. Check to ensure that the treatment received is in fact covered by your insurance plan, as otherwise, your medical claim may be denied.

6. If required, include a signed pre-approval form and your medical claims application.

How Does Medical Claims Process Work?

Medical claims go through several steps to ensure accuracy and approval. In fact, a medical claim actually begins even before you make an appointment to visit the doctor. As insurance plans are not all-inclusive, it is crucial to review your insurance policy documents and find out the services that are actually covered under your specific insurance plan.

This helps to determine what kind of health care services are covered under your plan and how to get to a health care provider who is part of your insurance carrier’s service network.

The processing of claims typically begins after the healthcare service has been provided and the claim submitted, not merely upon selecting a covered service or provider.

Once your doctor’s appointment is over, here are the steps that your medical claims application will go through:

1. The healthcare provider submits a claim to the insurance company for services rendered, excluding any copayment made at the time of service.

2. A claims processor reviews the claim for accuracy and verifies coverage under the patient’s insurance plan for the services billed.

3. If the services provided to you are covered under your insurance benefits, the insurance company will agree to pay the claim according to your coverage plan. The insurance may cover the full eligible amount according to the plan’s coverage limits and conditions. Any remaining balance not covered by insurance is the patient’s responsibility as an out-of-pocket expense.

4. The insurance will validate the charges and apply them to the patient’s deductible and out-of-pocket maximums as per the plan, updating these totals accordingly.

5. The insurance provider will then send a detailed list of benefits that explains the health care services received by the patient, the amount covered by insurance, the amount paid to the health care provider (doctor), and if any balance needs to be paid.

6. You will then receive a final bill for payment.

7. It is highly advisable to compare the EOB and final bill to ensure every detail is accurate and correctly billed. The balance may sometimes not match, which could be caused by a clerical error or mismatched medical code. In such situations, you can easily update and fix the claim without paying any penalty or fine.


If a medical claim is denied, you may contact your insurance provider to inquire about the denial and discuss potential resolution options. If it cannot be resolved, the claim will go through a formal review from the insurance provider, where it is evaluated more closely.

After this, the insurance provider may overturn the denial or determine that the case can be re-submitted using the correct information to seek approval.

See Also

EDD Disability

Grants for Healthcare Providers

Is Medical Insurance Tax Deductible

Are Medical Expenses Tax Deductible

Are Copays Tax Deductible

Are Medical Bills Tax Deductible

IDA Grant Program

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