Filing a health insurance claim isn’t exactly anyone’s idea of a good time. The process can feel technical, slow, and frustrating, but sometimes it’s necessary. A health insurance claim is a formal request for your insurance company to pay for medical services you've received. It’s usually submitted by your provider, but in some cases, like out-of-network visits or special reimbursements, you may need to file one yourself. Here’s what you need to know:

What situations might require you to file a claim? You might need to file a claim if:

You saw a provider outside your network.
You received care while traveling, and the provider didn’t submit a claim.
There was a processing error, and the claim wasn’t filed correctly.
You paid out-of-pocket for medical equipment or prescriptions and want reimbursement.

So, you need to file a claim. What’s next? Step one is to obtain a superbill. A superbill is an itemized receipt or summary of services provided. It’s the backbone of your claim, and you will need to request one from the provider or office staff. It should include:

The date of service.
Procedure codes and diagnosis codes.
Provider’s NPI and contact info.
Your payment information (if applicable).

From there, you will need to find the correct claim form from your carrier’s website. Most carriers will have a “medical claim form” available as a PDF or through an online portal, which can be found in your member portal. You will need to find the one that matches your type of claim, either medical, dental, or prescription. Step two is filling out the form. To do so, you will need:

Your member ID number (found on your insurance card) and personal information.
The superbill.
Provider details, such as name, NPI, and address.
Information about the care or service you received.
A short description of what happened.

The information you provide on the claims form must then be submitted along with the superbill to your carrier, either through the online portal messaging system or via mail. Here are some examples of what a Blue Cross Blue Shield and Aetna claim form looks like:

You can also check out our video on how to submit a claim to Blue Cross Blue Shield here.

Now that you’ve completed all the necessary steps to obtain your superbill, filled out the claims form, and submitted it to your carrier, what happens if your claim is denied? It happens more often than you’d think, but it doesn’t always mean you’re out of luck. Common reasons for denied claims may be as simple as missing information, such as incorrect codes or an incomplete form, to more complex reasons, such as a lack of prior authorization, or out-of-network providers and services not being included in your plan.

If your claim is denied, don’t panic! Insurers are required to provide a reason for denial and provide instructions for an appeal. If you decide to appeal, you can usually submit an appeal in writing or through your online account. Be sure to include:

A copy of the denial notice.
Any supporting documents (superbill, medical necessity letters, etc.).
A short, clear explanation of why you believe the claim should be covered.

It is still possible that your claim will continue to be denied. The best thing you can do if you find yourself in this situation is to keep detailed records of everything (especially when traveling or paying upfront) and double-check your information thoroughly. Even if the claim isn’t fully covered, it’s worth it to file, as you may be partially reimbursed even if the full claim is not covered.

Make sure you know your policy well, too; many claims are denied simply because the service isn’t covered, so be sure to read up before undergoing a procedure. If you find yourself stuck or unsure how to file a claim, reach out to us. We’re happy to help our clients navigate this process and walk you through it.

How to File A Health Insurance Claim

Insurance 101