Major Medical Coverage

In most cases, you won’t have to do a thing. Typically, your doctor’s office will submit a claim and you will not need to be involved in the process. Your doctor will send a bill to your insurance company for any charges you did not pay during a visit or submit a claim for the services they provided to you.

From there, a claims processor will check it for completeness, accuracy, and whether the service is covered under your health insurance plan. They will also verify important information like your copay and how much of your annual deductible and out-of-pocket maximum you have already paid throughout the year. If the service is covered, the insurance company will pay the doctor. 

Once that’s done, you will receive an Explanation of Benefits (EOB) that details how the care you received was paid by your plan. You may also receive a bill from your doctor for any charges left unpaid by you or your insurance company. After you receive the final bill, compare it with your EOB — the information should match the amount you owe.

While most providers handle this automatically, there are times you may need to step in. Common situations include:

• You saw an out-of-network provider
• You received care while traveling and the provider didn’t file on your behalf
• There was a processing error with your original claim
• You paid out-of-pocket for equipment or prescriptions and need reimbursement