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  · 3 minutes read

Demystifying Health Insurance Claims: What You Should Know

In the realm of health insurance, the term “claims” is a fundamental concept that directly impacts your healthcare journey and financial well-being.

What Are Health Insurance Claims?

Put simply, a health insurance claim is a formal request you or your healthcare provider submit to your insurance company for payment. It’s a detailed record of the medical services you received and the associated costs. When you visit a GP, undergo a medical procedure, or obtain prescription medications, these expenses are documented as part of a claim.

The Claims Process

  1. Service Received: It all begins when you seek medical care. Whether it’s a routine check-up, a specialist appointment, or a hospital stay, each service is documented and coded to indicate the nature of the care provided.
  2. Submission: Your healthcare provider, such as a GP’s office or hospital, usually handles the initial submission of the claim to your insurance company. They send all the necessary information, including your medical history, diagnosis, treatment details, and billing codes.
  3. Adjudication: This is where the insurance company reviews the claim. They check if the services rendered are covered by your policy and whether they meet the criteria for reimbursement.
  4. Payment or Denial: Once the claim is processed, your insurance company will either approve and pay the claim or deny it. If approved, the insurance company will pay a portion of the costs as specified in your policy. If denied, they will provide reasons for the denial.

Why Understanding Claims Matters

  1. Financial Responsibility: Understanding the claims process is crucial for managing your financial responsibility. It helps you anticipate costs, including deductibles, copayments, and coinsurance, and avoid unexpected medical bills.
  2. Coverage Confirmation: Monitoring your claims ensures that you’re receiving the benefits you’re entitled to under your insurance plan. If a claim is denied, you can dispute it or seek clarification from your insurance provider.
  3. In-Network vs. Out-of-Network: Claims can differ depending on whether you receive care from in-network or out-of-network providers. In-network care is often more affordable, so knowing the difference can help you save money.
  4. Prevent Fraud: Being aware of the claims submitted on your behalf helps you identify any potential instances of insurance fraud. If you notice unfamiliar or suspicious claims, report them to your insurance company immediately.
  5. Documentation: Keeping records of your claims and explanations of benefits (EOBs) can be useful for tax purposes and future reference.

In summary, by understanding the claims process and staying informed about the details, you can navigate the world of health insurance with confidence, ensuring that you receive the care you need while managing costs effectively, especially in the context of the UK healthcare system.

Tom McCabe picture

Tom McCabe

Co-founder and CEO of, a radically simple way for companies to offer health cover to their teams. International health cover, accessed with your Mo Mastercard, built on a collectively-funded Trust.

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