Insurance claim
Updated September 30, 2026
Definition
A request for payment sent to your health plan after you get care. Your provider usually sends it, but you may need to file it yourself in some cases.
An insurance claim is a request for payment that goes to your health plan after you get care. It lists who treated you, the date, what was done, and why, using billing and diagnosis codes. Your provider usually sends it for you. If you see an out-of-network provider, you may have to file it yourself.
Your plan reviews the claim and decides what it will pay. Then it sends you an explanation of benefits (EOB) with the result. A claim can be paid in full, paid in part, or denied.
If a provider bills you before the claim is done, the bill may show the full price. Ask the billing office to send the claim to your plan first, then compare the new bill with your EOB. If your plan didn't pay, see insurance didn't pay my medical bill.
Related terms
Guides that use this term
- GuideInsurance didn't pay my medical bill: what to do nextInsurance didn't pay your medical bill? Find out why, match the denial code to the fix, and learn when to ask for a rebill and when to file an appeal.
- GuideMedical bill vs. EOB: how to compare them line by lineYour bill and your EOB should tell the same story. Here's how to compare them in 20 minutes, with a worked example and what to do if they don't match.
Sources
- Claim (glossary), HealthCare.gov. Accessed September 30, 2026.
- Internal appeals, HealthCare.gov. Accessed September 30, 2026.
This is general information, not legal or medical advice. Rules can depend on your plan and your state. Romi Care isn't an insurer, law firm, collection agency, or government program.