Medical Insurance Claim
Request for payment of medical expenses from insurance company.
Detailed Explanation
A Medical Insurance Claim is a request submitted to a health insurance company for payment of medical services. Most claims are submitted electronically by healthcare providers, but patients sometimes file claims for out-of-network care or when providers don't bill insurance. Claims include: patient and insurance information, provider information, dates of service, diagnosis codes (ICD-10), procedure codes (CPT/HCPCS), and charges. The insurance company processes the claim by: verifying coverage, checking if services are covered benefits, applying deductibles and copays, determining allowed amounts based on contract with provider, and issuing payment to provider or reimbursement to patient. An Explanation of Benefits (EOB) explains how the claim was processed. Claims can be denied for various reasons (no coverage, services not medically necessary, incorrect coding), and appeal rights exist. Understanding the claims process helps patients navigate insurance and avoid surprise bills.