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 lists the number of diagnoses, tests, and treatments performed on 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 initiated when a patient checks into a healthcare facility. This claim is applicable for the duration of the healthcare services rendered to the patient till they receive the final bill.

If a patient visits a doctor outside the covered network, medical claims can be filed by the patient. 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 doctor will collect the patient’s claim application, along with relevant evidentiary documents from the insurance forms the patient fills out.

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

The medical claim form will go through an insurance claims process. The insurance company will cover the bill amount per 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.

Once you know the kind of healthcare services that are covered and can find the relevant doctor, the claims begin being processed immediately.

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

1. The doctor’s office sends a service bill to the insurance provider (this does not include charges paid through co-pay on check-in).

2. A certified claims processor will evaluate the claim to ensure accuracy and compare it with your specific insurance plan to ensure that services rendered and billed are covered under your insurance benefits.

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 carrier may pay the final amount in full if your plan permits. The remaining balance is borne by the policyholder/patient as an out-of-pocket expense.

4. The medical charges in the medical claim application will be validated and applied to deductible and out-of-pocket totals, as applicable under your insurance plan, which will also be updated immediately.

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 your medical claim gets denied, you can call your insurance agent to resolve it over the phone. 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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