Steps of a Healthcare Claim Landing Page

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The 4 Steps of a Healthcare Claim

When you visit a healthcare provider for the first time, there's usually a lot of paperwork to fill out. They want to know your health history, and also information about your insurance company, your member ID and more. This gives your doctor's office the basic information they need so that they can start the process of a "claim" - that's what they call bills in the industry - and get paid by both you and your insurance company for the services they provide.

The claims process generally involves four steps.

1. Paperwork - and request for payment - from the doctor's office.
During your appointment, your healthcare provider will take notes about any medical conditions they diagnose, tests ordered and services provided. Each of these things will have a code. Usually, the doctor's office will submit these line items and codes to the insurance provider and request payment. (In some cases, like if a provider is not in the patient's network, the patient may submit the claim, themselves).
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2. Paperwork - and payment - from the insurance company.
At the insurance company, someone called "a claims processor" looks through the claim to make sure that the procedures, devices, medications and services listed are covered by your plan. If they are covered, the company will pay the allowable amount to the healthcare provider.
3. Paperwork for the patient.
The insurance company sends the patient an Explanation of Benefits (EOB) document. This is not a bill, it's simply a breakdown of charges and payments, including what your health insurance company is paying for, what they're not paying for, and what the patient is responsible for.
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4. Payment by the patient.
Now that the insurance company and the healthcare provider have determined who's paying what, it's your turn! The healthcare provider's office will send you a bill for any co-pays, co-insurance, deductibles or other charges due. These numbers should be the same numbers you saw on the EOB. If something is different, ask your insurance company and your doctor's office to work together to resolve the issue.