​​​How to File a Health Insurance Claim​​

Most providers file insurance claims for you. That’s why they need your insurance card when you see them. The providers send a bill to your health plan with information about your condition and how they treated you. Your health plan compares your benefits with the services billed and pays your provider. This payment won’t include any ​amounts that are your responsibility – for example, the deductible, co-payments, or coinsurance. If the plan doesn’t cover any part of your claim or doesn’t cover the health care service, your health care provider can ask you to pay the balance. If you’ll owe coinsurance, many providers estimate the amount and ask you to pay that when you see them​. 

Some health care providers won’t submit claims for you. You can ask your providers if they will. If you have to submit your own claim, ask your provider to help you so you have the right dates, procedures, and codes on the claim form. Keep in mind that when you submit your own claim, most providers require you to pay the full amount upfront. Then, your health plan will reimburse you after it processes the claim.​

When your health plan pays your claims

If your provider submits your claim, don’t pay a bill for a covered service until your health plan has reviewed the claim. ​​

How do you know if the plan has reviewed the claim? Your health plan will send you an “Explanation of Benefits” (EOB) after you receive services. The EOB tells what services the plan paid or didn’t pay, and why. 

Your health plan must explain in writing within a set amount of time why it didn’t pay for a service. If you think the plan should have paid for the service, you can appeal the decision.

Your health plan must tell you how you can appeal their decisions. If taking the time to appeal would put your life or ability to fully function at risk, you can file an “expedited” appeal to get a quicker decision.​​

Your insurer may fully or partially deny a pre-authorization request or a claim for coverage if services are not covered by your health plan or if it believes services are not medically necessary. For example, your insurer may say that care is custodial but you think it is medically necessary. If you believe your request for pre-authorization or claim has been wrongly denied, you can file an appeal with your insurer. The instructions for filing an appeal will be in your policy, and may also be in the Explanation of Benefits letter, or in your health plan’s Summary of Benefits and Coverage. 

The Health Education and Advocacy Unit (HEAU) of the Consumer Protection Division in the Office of the Attorney General​ can help you file an appeal. You can email them at [email protected]​ate.md.us or call 410-528-1840 or toll free at 1-877-261-8807 Monday – Friday from 9 a.m. – 4:30 p.m. You can also file your complaint online or by mail. 

If your health plan is subject to Maryland law, you may also be able to file a complaint​ with the Maryland Insurance Administration (MIA) by calling 410-468-2340 or toll free at 1800-492-6116. Generally, you must appeal the decision through your health plan’s appeal process before filing a complaint with the MIA. But in some situations, you may be able to file a complaint with the MIA even if you have not completed your health plan’s appeals process. 

If your health plan is not subject to Maryland law, you may still have the right to an external review of the health plan’s decision. You should read your policy for instructions about how to request this, or contact the HEAU​ for help.

Get free help with your health coverage! ​

The Maryland Insurance Administration has a Health Coverage Assistance Team (H-CAT) to assist consumers. If you have questions or concerns about health coverage for you or your loved ones, the H-CAT staff is here for you.