What Is a Health Insurance Claim?

What Is a Health Insurance Claim?

What Is a Health Insurance Claim?

We’ve all done it before: sat in a doctor’s office and filled out form after form with our insurance information. Ever wonder why they need all that info? Well, your doctor’s office needs it so that they can file a claim with us. 

A claim is simply a bill your doctor and other health care providers send to a health insurance company (such as Blue Cross and Blue Shield of New Mexico) for payment after they have treated you.

In most cases, your provider’s office will submit the claim for you so you don’t have to worry about it. But there are some instances when you may have to file the claim yourself, such as when you get care from an out-of-network provider. Which brings us to the next question: How do you file a health insurance claim?

How to Submit a Claim

If you have to file a claim, here’s what you need to do:

  1. Print out a “Medical Claim Form” from the “My Account” section in Blue Access for MembersSM. Look for the Forms and Documents section.
  2. Fill out the form completely. You’ll need to have this information handy:
    1. Date of service/treatment
    2. Type of service
    3. Dollar amount charged by the health care provider
    4. Member ID number (found on your ID card)
  3. Mail the form and the original bill issued by the provider to the address printed at the top of the claim form
Some Tips
  • Make copies - It’s a good idea to make copies for your records because the bill you send in with your claim will not be returned to you.
  • Don’t wait too long - Be sure to file your claim soon after you receive care. This is more important when you have a claim from late in the year and you need to make sure your 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:

Blue Access for Members

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

  • Paid - The health care services you received were covered by your health care benefits plan and the claim has been paid.
  • Not Paid - The health care services you received were not covered by your health care benefits plan.
  • Processed - The health care services you received were covered by your health care benefits but no payment was required.
Explanation of Benefits (EOB) Statement

Once your claim has been processed by us, you will receive an EOB, either by mail or email. This document will break down:

  • The amount billed by your provider
  • Medical benefits that were approved (how much we are paying)
  • Amount you may still owe your provider

If your claim has been denied, you can file an appeal to have it looked at again. The appeals information is located with your EOB.

Still have questions? Ask us in the comments!

Originally published 2/10/2015; Revised 2022