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Search claims.
Log in to look up your own claims and explanations of benefits. If you are trying to work out why a bill says what it says, this page walks through how a claim is filed, processed, and paid.
How claims work
From the appointment to the bill.
A claim is the request for payment your provider sends to your plan. Five things happen, always in this order, and knowing which one you are waiting on tells you who to call.
You get care.
You show your ID card, and the office records what was done using standard billing codes. Nothing about your cost is decided in the room.
The provider files the claim.
In-network providers submit claims for you, usually within days. If you saw someone who does not bill your plan, you may have to file it yourself using a member claim form and the itemized receipt.
The plan processes it.
The plan checks that you were covered on that date, that the service is a covered benefit, that any required authorization was in place, and what the allowed amount is. Most clean claims are processed in a few weeks.
You get an explanation of benefits.
The explanation of benefits shows the billed amount, the allowed amount, what the plan paid, and what you owe. It is a statement, not a bill. Keep it to compare against whatever the provider sends you.
The provider bills you the remainder.
You pay the provider for the patient responsibility shown on the explanation of benefits. If their bill is higher than that number, ask the office before paying, because it usually means a billing error or a service the plan handled differently.
Claim status
What each status actually means.
Wording varies by plan, but nearly every claim sits in one of these four states.
Received
The claim is in the queue.
The plan has the claim but has not finished reviewing it. No action is needed from you at this stage.
Pending
Something is missing.
The plan is waiting on information: medical records, an authorization, an accident questionnaire, or proof of other coverage. Claims sit here until whoever was asked responds, so it is worth calling to find out who that is.
Processed
The split is decided.
The plan has calculated the allowed amount, its share, and yours. Your explanation of benefits follows, and the provider is paid their portion.
Denied
The plan is not paying.
A denial always comes with a reason code and appeal instructions. Many denials are administrative, such as a missing authorization or a coding error, and are resolved by the provider resubmitting the claim.
Explanation of benefits
Six things to check on every one.
An explanation of benefits is not a bill. Read it before you pay anything, and treat any mismatch as a question rather than a debt.
- The date of service and the provider name match a visit you actually had
- The service codes reflect what was done, not something more extensive
- The plan applied the in-network allowed amount if the provider is in network
- Amounts credited to your deductible or out-of-pocket maximum look right for the year so far
- The patient responsibility line matches the bill the provider sends you
- Any denial line has a reason code you can look up or ask about
Good to know
Claims questions.
Do I ever have to file a claim myself?
How long do I have to submit a claim?
My claim was denied. What now?
What is an explanation of benefits?
I got a surprise bill from someone I never chose.
Rethinking your plan
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