What Is a Health Insurance Claim?

We’ve all done it. Shown or uploaded our member ID card when filling out insurance forms in the doctor’s office or through an online portal. Your doctor’s office needs these details so they can file a claim.

A claim is a bill your doctor and other health care providers send to a health insurance company for payment after they have treated you. In most cases, your provider’s office will submit the claim so you don’t have to worry about it. Still, there are times when you may have to submit a claim yourself. For example, if you choose to get care from a provider who's not in your plan's network.

How to Submit a Claim

If you need to submit a claim:

1. Go to our Form Finder tool. You’ll find the forms you need to manage your health insurance plan in once convenient place.
2. Scroll the page to find the claim form you need. You can choose from:
   • Dental
   • Medical (Domestic)
   • Medical (International)
   • Prescription Drug (Prime Therapeutics)
3. Click the Download icon to the right.
4. Fill out the form fully. You’ll need this information to complete the form:
   • Date of service/treatment
   • Type of service
   • Dollar amount charged by the health care provider
   • Member ID number (from your ID card)
5. Print the completed form and mail it — along with the original bill from the provider — to the address at the top of the claim form.

Some Tips

• Make copies. The bill you send in with your claim will not be returned to you, so you’ll want to have a copy.
• Don’t wait too long. Be sure to file your claim soon after you receive care. This is even more important when you go to the doctor late in the year and need to make sure the claim is applied to the right plan year.

Check the Status of a Claim

There are a couple ways you can check the status of your claim:

•  Visiting the “Claims” section in Blue Access for Members
• Call the customer service number on your ID card

Blue Access for Members

Please note the claim will not show up in Blue Access for Members until it is processed. There are five types of claims statuses that you may see:

• Fully Paid: The health care services were covered and paid for by your health care benefits plan. You are not responsible for any part of the bill.
• Partially Paid: The health care services you received were partially paid by your plan. You may still be responsible for part of the bill.
• Discounts Applied: Your plan negotiated discounts and reductions with your provider. You may be responsible for part of the bill.
• Not Paid: The health care services you received were not paid by your plan. You may be responsible for all or part of the bill.
• No Action Needed: The health care services you received were not paid by your plan, but you are not responsible for any part of the bill.

Explanation of Benefits (EOB) Statement

Once we process your claim, you will receive an EOB, either by email notification directing you to BAM or mail. This document will break down:

• Amount billed - The amount billed by your provider.
• Discounts and reductions – Cost savings offered by your plan.
• Amount covered – The amount billed minus any discounts and reductions.
• Health plan responsibility – The amount your health plan pays to the provider.
• Deductible – Before your health plan starts to pay for medical care and prescription costs, you pay 100% of these costs until you reach a set dollar amount known as your deductible. Once you pay your deductible in full, you then cover only your copay and coinsurance costs.
• Copay amount – A set amount you pay every time you see a doctor or get a prescription filled. Your copay is listed on your member ID card.
• Coinsurance – Your share of costs you pay for care after you’ve met your deductible. It may be a percentage of the cost, or a set amount.
• Amount not covered – Costs not covered by your health plan.
• Your total costs – The amount you may still owe your provider.

If your claim was not paid, you can file an appeal. The appeals information is included with your EOB.

Originally published 2/10/2015; Revised 2022, 2024