Whether you visited your doctor’s office for routine care or ended up in the emergency room with a broken wrist, you’ve probably received a medical bill. But do you know what happens before the bill makes its way to you?
No? You’re not alone. The medical claims process is a mystery to many, and reading a medical claim or the bill that comes from your doctor’s office isn’t always straightforward. But don’t worry, we’ll walk you through everything you need to know – from the types of claims to how they’re filed and everything in between.
What is a medical claim?
A medical claim is an invoice (or bill) that is submitted by your doctor’s office to your health insurance company after you receive care. Each claim has a list of unique codes that describe the care you received and help your health plan process and pay them faster.
HealthPartners members can view processed medical claims in their online account anytime.
The common types of claims
There are different types of claims, depending on the care you get and the plans or products you have, including:
Medical claims
A bill that your doctor sends to your health insurer for your medical care. These can be from a doctor's office, urgent care, hospital, emergency room or any other provider who cares for your body.
Dental claims
A bill that your dentist, orthodontist or oral surgeon's office sends to your health insurance for your dental care.
Pharmacy claims
A bill that your pharmacy sends to your health insurance company for medications that you have gotten. This can be for regular prescriptions or for medications you needed while receiving other care, such as in the hospital. In that case, you may have both medical and pharmacy claims for the same care visit.
Consumer-directed health plan (CDHP) claims
Claims that you submit for health care expenses you've paid for that can be reimbursed by a pre-tax account, such as a flexible spending account (FSA) or health reimbursement account (HRA). These might include bills that you've received for care or prescriptions, as well as other approved expenses like eyeglasses or over-the-counter medications. These are submitted by you directly to the company that administers your FSA or HRA.
How a medical claim is created
If you received care in your plan’s network, your doctor’s office will submit a claim on your behalf. This happens automatically and you generally don’t need to be involved in the process.
But if you received services outside the network, you may need to file a claim yourself. If you’re a HealthPartners member, the best way to do this is to submit a claim online.
How long you have to file a medical claim for out-of-network services
To make sure your medical bills are processed quickly and paid on time, the sooner you file your medical claim, the better. Many health insurance companies give you up to 90 days after the date you received care.
How health care claims processing works
Let’s follow the life cycle of a medical claim from the moment you check in at the doctor’s office until you receive a bill:
- You fill out an intake form at your appointment with your personal information and insurance details.
- The doctor’s office verifies your insurance information.
- You receive care. Your doctor or care team makes notes in your medical record about the care you received, what you talked about, and any medications that you were prescribed at that visit.
- Your doctor’s notes are copied into standardized medical codes to describe the care you received and why.
- A medical billing specialist at the doctor’s office enters the prices that the clinic charges for each medical code onto a health insurance claim form. This is often an automated process and tells your insurance company the cost of the care you received.
- Your claim is transferred from your doctor’s office to your health insurance company. This is often done electronically.
Your doctor’s office decides how often they send claims. Many send them daily, but some send them weekly or even monthly. They may also send the claims for certain types of care in batches – such as if you got multiple physical therapy appointments, the claims might be sent in a batch of three or four visits at a time. How your doctor’s office sends claims will affect how quickly and in what order your health plan pays them.
- Your health insurer makes sure the information sent by your doctor’s office matches standard medical codes, then compares it to your health plan benefits and figures out what’s paid by your plan and what you’ll owe. If there are any coding discrepancies, your health insurer may send questions back to your doctor’s office to clarify what care you received.
It's important that the codes are correct, as they can change what benefit your care is covered under. For example, if the medical code indicates that you had a screening mammogram, that’s generally covered by your plan’s preventive services benefit. But if the code is for a diagnostic mammogram, that indicates you had symptoms that required the mammogram to diagnose a problem. That would likely be covered by your plan’s diagnostic imaging benefit. Those benefits have different coverage, so what your plan pays and what you’ll owe would differ.
- Your health plan completes processing the claim. It sends a payment to your doctor’s office for the cost covered by your plan and tells them what you still owe to cover the full cost.
- You will often receive an explanation of benefits (EOB) from your health insurer about the claim, explaining how it was paid and what you owe. And you will receive a bill from your doctor’s office for any costs not covered by your plan. You pay that directly to your doctor’s office.
How long health insurers have to pay claims
Your health plan must let you know if your claim is being accepted or denied within 30 business days of receiving a claim. HealthPartners pays most submitted claims within four weeks.
But processing a claim can take longer if all the necessary information wasn’t included in the original claim submission, if medical codes don’t match or if other errors were made.
How to read a medical claim and EOB
The formatting of your medical claim and EOB will vary by insurance company, but it usually includes common health insurance terms like:
- Total cost of service: This is the total cost of the care that you received. If you didn’t have insurance, this is the amount you would be billed.
- Member savings: This is the discount you’re getting on the total cost of the service by being a member of your health plan. Health insurance plans like HealthPartners represent hundreds of thousands of members, so they can negotiate more affordable prices on your behalf.
- Plan paid: This is the amount that your health plan paid for your care. This will vary by the type of service, as well as where you’re at in your deductible or out-of-pocket maximum.
- My responsibility: This is the amount you owe. Your doctor, clinic or hospital will send you a bill for this amount.
The importance of a medical claim number
Each medical claim has a unique claim number assigned to it to make it easy to identify. So, when you reference that number to someone at the clinic or member services at your insurance company, they’ll be able to know what visit you’re talking about and be more prepared to answer your questions.
If you’re a HealthPartners member, you can find your claim number in the top-right corner of your EOB.
What if my claim is denied?
You will be notified on your Explanation of Benefits if your claim is denied, and why.
A claim could be denied for a variety of reasons, including that your plan doesn't cover some of the care you received, or it was from a clinic or doctor that isn't covered. It may also happen if your health plan hasn’t received additional information they need to process the claim, like Coordination of Benefits details.
If your claim is denied, you may have the right to ask that it be re-reviewed by filing an appeal.
Submitting a medical claim to HealthPartners
If you have a question about how to file an out-of-network claim with us, we’re here to help.
If you’re a HealthPartners member, you can sign into your online account to view your claims and EOBs or call Member Services at the number on the back of your member ID card.