A simple guide to help members understand the claims process, what an Explanation of Benefits means, and what to do next.
Why this matters
Claims can feel confusing because members may see several pieces of information after a healthcare visit, including a claim, an Explanation of Benefits, and sometimes a bill from their provider. This guide helps make the process easier to follow by showing what happens, who is involved, and what members should check before they pay.
The Claims Journey: Step-by-Step Process
- A member gets care: A member visits a doctor, hospital, clinic, pharmacy or other healthcare provider.
- The claim is created: It’s created by the member’s provider and includes a breakdown of the care received and the cost for each service.
- The claim is submitted: The provider sends the claim to the health insurance plan. In some cases, the member may need to submit information.
- The claim is reviewed: The health plan checks the member’s benefits, the provider’s network status, covered services, and plan rules. Sometimes additional information may be requested from the provider.
- The claim is processed: The health plan determines what the plan pays and what, if anything, the member may owe. Sometimes this process takes a while. We want to be sure the claim is processed correctly and our members get all the benefits of their insurance.
- An EOB is available: The health plan sends an EOB. This explains how the claim was processed. It also explains whether the claim was paid or why it was denied. If there is an outstanding balance to pay, that’ll be there too. The EOB is not a bill.
- The bill may arrive: If the member owes money, the provider will send a separate bill. The member should compare it to the EOB before paying.
Important reminder: An EOB is not a bill
An Explanation of Benefits, often called an EOB, is a statement from the health plan that explains how a claim was processed. It shows the services provided, what the provider charged, what the plan allowed, what the plan paid and what the member may owe. Members should wait for the provider’s bill and compare it to the EOB before making a payment.
What members should check
- Make sure the member name, provider name and date of service are correct.
- Confirm the service listed matches the care received.
- Look at what the provider billed, what the health insurance plan paid, the member discount and what the member may owe to the provider.
- Compare the EOB to any bill from the provider before paying.
- If something looks wrong, contact the provider for billing questions or the health plan for coverage questions.
