Last Updated: March 20, 2026
What is a Healthcare Claim?
A healthcare claim is a request for payment that you or your doctor submit to your health insurance company after you receive care. The claim includes unique medical codes that have been interpreted from the healthcare providers notes during your visit. Using these codes, the insurance carrier will determine whether the healthcare services provided are covered in full, partially covered, or not covered and require additional payment from the patient.
The Creation of a Healthcare Claim
Presenting Your Healthcare ID Card
Giving your personal and healthcare insurance information to your provider is the first step in creating a healthcare claim. Always bring your healthcare ID card with you to an appointment with your healthcare provider.
Pro-Tip: it's always best to contact your Insurance Carrier before going to your appointment to make sure your provider is in-network and the services you are going in for are covered under your policy.
Insurance Verification
The second step in generating a claim is verifying your insurance. Insurance verification confirms that you have coverage for the care you are about to receive, outlines your policy benefits, and indicates whether your insurance provider requires prior authorization for the intended healthcare services.
Coding
During a patient’s visit, the healthcare provider will take notes, which are then sent to their staff for coding. These codes signify diagnoses, procedures, medications, and supplies administered, as well as the reasons for each. Here are some examples of common medical codes:
- Current procedural terminology (CPT)
- Diagnosis-related group (DRG)
- Healthcare common procedure coding system (HCPCS)
- International classification of diseases (ICD-10)
- National drug code (NDC)
Listing of Charges-Services
Before care providers submit their coded claim for evaluation, they will list the charges for their services based on their contracted rates with the insurance provider.
The Claim is Submitted
Once the healthcare provider has completed the claim, it is submitted to the insurance company for processing.
Claim Evaluation
Once the insurance provider receives the claim, they evaluate the claim and determine:
1. Whether the claim is valid
2. How much of the charges they will cover
The insurance company will accept the claim and reimburse the charge if the patient has sufficient coverage and has obtained any required prior authorization.
The insurance company can reject the claim if it does not meet formatting requirements, has a medical coding error, the patient does not have sufficient coverage, or failed to obtain necessary prior authorization.
Rejected medical claims can be resubmitted for payment once the errors have been corrected.
Explanation of Benefits and Final Billing
Once the insurance provider determines their participation in the claim, an Explanation of Benefits (EOB) will be issued, followed by a final bill sent to the patient for any additional payments that may be owed.
Some providers require or request that you pay an amount upfront. If you do, keep a receipt of any prepayment and make sure it is accounted for in the final billing. If you overpay, you may have to initiate reimbursement directly from the provider. In some cases, they may retain the balance and apply it to future services.
Do not make any payments until you receive the Explanation of Benefits from your insurance carrier and compare it with the bill from your provider.
Information Sources:
https://www.definitivehc.com/blog/medical-claims-101-what-you-need-to-know
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