Claim
A claim is a formal request made by a healthcare provider or an insured individual to an insurance company for payment of services rendered or medical expenses incurred.
What is a Claim?
A claim is a request for payment that you or your healthcare provider submits to your health insurer when you get items or services you think are covered. It is essentially a bill that your doctor, dentist, or pharmacy sends to your health insurance company for the medical, dental, or prescription care you have received.
Each claim includes a list of unique codes that describe the care you received, which helps your health plan process and pay them faster. Claims are submitted after the care has been provided, as opposed to prior authorization which happens before a medical procedure. You will often receive an Explanation of Benefits (EOB) from your health insurer about the claim, detailing how it was paid and what you owe, in addition to a bill from your provider for any costs not covered by your plan.
What is the difference between a Claim and Prior Authorization?
A claim is a request for payment submitted after care has been provided, detailing services received. Prior authorization, in contrast, occurs before a medical procedure to determine coverage.
A claim is a request for payment submitted to a health insurer after receiving items or services.
Prior authorization happens before a medical procedure.
A claim is essentially a bill from your provider to your health insurance company.
Claims include unique codes describing the care received to help with processing and payment.
What are examples of a Claim?
After a visit to your primary care physician, the doctor's office sends a claim to your health insurance company for the services provided during your check-up.
When you fill a prescription at the pharmacy, the pharmacy submits a claim to your health insurer for the cost of the medication.
If you have a dental cleaning and exam, your dentist's office will send a claim to your dental insurance provider for payment of those services.
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