How to Prepare a Health Insurance Claim

Request itemized medical bills from every provider involved in your care. An itemized bill lists each service, procedure, and supply by billing code and unit cost. Summary statements that show only a total amount are not sufficient for claim review or dispute. Most providers are required to provide an itemized bill upon request.

Save all Explanation of Benefits (EOB) forms from your insurer. The EOB is issued after each claim is processed and shows what was billed, what the insurer paid, what was applied to your deductible, and what you owe. EOBs are the primary document for identifying underpayments, incorrect processing, or erroneous denials.

Keep copies of all prior authorization approvals and referral documents. If your insurer approved a procedure in advance, that approval is relevant evidence if the claim is later denied or paid at a lower rate. Document the approval date, the reference number, and the name of the person who issued it.

If a claim is denied on medical necessity grounds, request the clinical notes and documentation from your treating provider that support the medical necessity of the procedure. These records are essential for the internal appeal.

Save all prescription records and pharmacy receipts. If a pharmacy claim is denied or paid at the wrong rate, you will need the prescription date, the drug name, the prescribing provider, and the fill date.

Keep a written log of every phone call with your insurer. Record the date, the name of the representative, the reference or call confirmation number, and a brief summary of what was said. This log is important if you need to demonstrate that the insurer was informed of a treatment before it occurred.

Contact your insurance company's member services or claims department — the phone number is on the back of your insurance card — as soon as you receive a denial or believe a claim was processed incorrectly. For scheduled procedures, confirm benefits and prior authorization requirements before the service occurs to avoid downstream claim disputes.

Contact your healthcare provider's billing department to obtain itemized statements and to clarify any billing code questions. Providers can also correct billing errors and refile corrected claims, which resolves many disputes before a formal appeal is needed.

Contact your state Department of Insurance if an internal appeal is denied and you believe the insurer's decision violates your policy terms or applicable law. The DOI can review your complaint and compel a response from the insurer. All DOI contact information is publicly available on your state's DOI website.

If you believe you have received a surprise medical bill in violation of the No Surprises Act — which protects patients from certain out-of-network bills for emergency services and some non-emergency services at in-network facilities — submit a complaint to CMS at cms.gov/nosurprises. The federal No Surprises Act took effect January 1, 2022.

A patient advocate or patient assistance coordinator at the hospital or health system can help you navigate the billing and appeals process. Larger hospitals typically have dedicated patient financial services departments. This is a free service.

For in-network providers, the claim is typically submitted electronically by the provider at the time of service or shortly after. Under federal rules, group health plans must process clean claims within 30 days (electronic) or 45 days (paper). State regulations may provide additional protections. Check with your insurer for their specific processing timeframes.

If a claim is denied, your insurer is required to send a written denial notice that identifies the specific plan provision or policy reason for the denial and provides instructions for how to file an internal appeal. The denial notice must also inform you of your right to an external review if the internal appeal is denied.

The internal appeal process allows you to submit additional documentation and request that the insurer reconsider the denial. For non-urgent claims, insurers have 30 days for pre-service appeals and 60 days for post-service appeals under federal rules. For urgent pre-service appeals (for care you have not yet received), the insurer has 72 hours.

If your internal appeal is denied, you have the right to an independent external review through your state Department of Insurance or through a federally-designated independent review organization. The external reviewer is not employed by the insurer and is required to make an impartial determination based solely on your policy terms and applicable law.

Do not pay a bill before you receive and review the corresponding EOB. The EOB shows exactly what the insurer agreed to pay and what your actual cost share is. Paying before reviewing the EOB can result in overpayment, and recovering those funds from a provider is more difficult after payment is made.