Do you ever think about how health insurance claims are filed and processed? If so, you are not alone. Many people are in a similar situation as they do not fully understand how to claim health insurance benefits, leaving them vulnerable to malpractice from medical providers or insurance companies.

At Align Senior Care, we believe in ensuring everyone understands how insurance claims work to empower them and protect them from malpractice. As a result, we have found it necessary to explain some of the complex terms and processes involved in health insurance claims.


Understanding Health Insurance Costs

Health care claims processing can be complicated, if not downright frustrating. Align Senior Care simplifies the process so you can focus on what matters most – your loved ones. Here are the most frequent health insurance claim questions we are asked daily.


How Does Claims Processing Work?

The health care claim process starts at the doctor’s office, which will submit a claim to your insurer. You are not required to participate in this process, as the doctor will bill your insurer for the charges you are not directed to pay during your visit. The claims process involves the doctor and the insurance company’s claims processor.

The claims processor reviews the doctor’s claim for accuracy, completeness, and legitimacy. Furthermore, the claims processor confirms whether the services billed are covered under your health insurance plan. Additionally, the claims process verifies your copay, annual deductible already paid, and any out-of-pocket expenses you might have incurred.

Once the claim is verified and the insurance company confirms the service rendered is covered under your health insurance plan, the insurance company will pay the doctor. The amount paid to the doctor will depend on the benefits of your insurance plan. For example, the insurance company might pay a portion or the entire service cost based on your insurance plan.


What Happens After the Claim is Processed?

Once the claim is processed, the insurance company determines how much it has to pay the medical provider based on your health insurance plan. The appropriate amount is disbursed to the health care provider once the claim and payment are approved. The insured party will receive notice of the payment in the form of an explanation of benefits (EOB).


What is an Explanation of Benefits?

An explanation of benefits (EOB) is a document where the insurance company explains a claim. The EOB focuses on the insurance coverage and the total amount you must pay as the insured party. An explanation of benefits provides clarity on any claim filed by a health service provider or insured party to avoid misunderstandings in the future.

The EOB mainly contains the following information:

  • The cost of the care received 
  • Any savings made by visiting in-network health care providers
  • Any out-of-pocket medical expenses an individual is responsible for

Insurance companies tend to advise clients to seek services from in-network providers as they have lower charges due to mutual agreements.


Is my Explanation of Benefits a bill?

The explanation of benefits is not a bill to an insured individual. Instead, an insurance company sends the EOB to clarify the charges accrued from the health care service they received and might contain information on any charges the client has paid in the form of copay or might still owe. 

The doctor will send a separate bill if the individual still owes money after the insurance provider has paid its portion. The amount required from the medical provider in its bill to you should match the patient’s costs as listed in the explanation of benefits provided by the insurance company.


Get Health Insurance Coverage from Align Senior Care

Did you know that purchasing a health insurance plan from Align Senior Care is not the end of our relationship?

We offer additional support after your purchase. Our support staff is here to help you with any issue you might have. Be it confusing insurance terms or unfamiliar claims processes – Align Senior Care is here for you.

Call us at 1-844-305-3879 (TTY 711) or send an email for more information about senior health care plans offered by Align Senior Care.


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