How to Decode Insurance Claims


Review your explanation of benefits for accuracy. Under the section for member information, double-check that the name of the person who has purchased the insurance is listed, and the member identification number and plan number corresponds with what is shown on your member identification card.


Locate the patient information on the explanation of benefits. The patient area will list the name of the person who was seen by the doctor, their relationship to the insurance member and their patient identification number. This will be the same if the member is also the patient.


Look at each detailed line of your explanation of benefits. Each line will list the name of your doctor, the date of the doctor's appointment, the amount the doctor billed your insurance for the procedure, the amount your insurance allowed for the procedure, the amount insurance paid to your doctor and the amount you may owe your doctor.


Review the billing statement received from your doctor. Similar to the explanation of benefits, the statement itemizes each procedure performed on the date of your visit and the corresponding charges. It also indicates if your insurance carrier sent a payment for your visit.


Compare your explanation of benefits line-by-line to the billing statement your doctor sent to you. For each charge shown on the billing statement, locate the corresponding charge on the explanation of benefits. If they do not match up, call and ask your doctor's office for help in understanding the differences.

Tips and Warnings

  • If you receive a billing statement from your doctor and there is no indication of insurance being processed, it may be a timing issue and does not mean your provider failed to submit your claim to insurance. Call and clarify this with the office. Also, if the billing statement youreceive is not itemized, you can call your provider and ask for one to be sent.
  • If you pay your doctor's bill before insurance is processed, you may over pay. If you have paid your doctor more than the explanation of benefits shows you owe, call your provider and ask for a refund.
  • When you go to visit your doctor, her office submits information electronically or via paper, to your insurance company. This information becomes a claim. Your claim itemizes all the procedures your doctor provided to you and the diagnosis given. This information is processed by your insurance carrier who decides based on your health insurance plan how much the doctor is allowed to charge, how much the carrier will pay the doctor and how much of the claim you are responsible for paying.