What shows up on a health insurance bill?

Are you curious about what information shows up on a health insurance bill? What shows up on a medical insurance bill is a description of services, the codes used by the insurance company, and the balance owed. The total balance varies based on how much your insurance covers. After the health insurance company files your claim, your physician will bill you directly if you owe anything.

The information you receive from your health insurance after a doctor’s appointment isn’t a bill — it’s an explanation of benefits, including your name, date of birth, provider’s name, date of service, and a description of what insurance paid.

You should never pay a health insurance bill until you confirm your insurance company made all the necessary payments. Medical insurance billing can be confusing, but this guide will walk you through the medical billing process and discuss what shows up on a medical insurance bill and an EOB.

What shows up on a medical insurance bill?

Every medical insurance bill includes a description of services, Current Procedural Terminology (CPT) code, diagnosis (Dx) code, the amount charged for each service, and the total balance owed. For example, your health insurance bill for an adult wellness exam would state the CPT code for the exam, service name, and cost.

Take a look at your medical bill and note the following:

• Account number. An account number is your unique number with the healthcare provider for paying bills online or over the phone.
• Service date. Confirm your appointment date matches the service date on the bill.
• Description of services and charges. The service type you received and the total cost of each.
• Billed charges. Billed charges include the total cost of services.
• Insurance payments. The amount your insurance company paid.
• Patient payments. The remaining amount you’re responsible for paying.

The CPT and Dx codes listed by the description of services on your bill represent all of the services offered by healthcare providers. Claims adjusters and physicians use these codes to confirm which services your policy covers. Confirm you received each service listed on the bill and contact your healthcare provider if there’s a mistake.

The total balance owed on the medical bill will first go to your health insurance company. You won’t be responsible for any payments until the insurance company processes the claim and sends payment to your medical provider. Your doctor will bill you directly if there is a balance remaining.

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How long does a medical provider have to bill you?

State insurance laws determine how long a medical provider has to bill you, ranging from three months to three years.

To speed up the medical billing process, confirm your insurance company covers the medical services when you first make your appointment. 

Check your health insurance policy to verify your doctor is in-network or call the insurance company directly. Some healthcare providers require preauthorization from the insurance company before rendering services or prescribing medication. Your physician can confirm your coverage applies when you give them your health insurance card.

Read more: How do I get a new health insurance card?

The doctor’s office will create an insurance claim for your appointment and send it to your insurance company. However, you may have to pay coinsurance or copay at your appointment, depending on your policy type.

Finally, a claims processor who works for your insurance company will review the claim and confirm or deny any procedures based on your coverage.

While the insurance company processes the claim, you may receive an EOB statement in the mail. This statement explains your coverage, services covered by the policy, and how much your insurance company will pay.

What’s the difference between a health insurance bill and an explanation of benefits?

Is the EOB a bill? No, it isn’t. When you receive an EOB from your insurer, it will break down:

• The amount charged by the healthcare provider
• What the insurance company agrees to pay
• The remaining balance

Most insurance companies send an EOB to insurers after the physician’s office gets paid. In some instances, the insurance may send an EOB before the claim gets paid to alert you the claim was filed or notify you there was an issue with the claim.

Patients may owe their physician copays, coinsurance, health insurance deductibles, or other services the insurance company denied. Although there may be a remaining balance, it’s important to remember that an EOB is not a bill.

Your physician’s office will charge you directly if there’s a remaining balance after paying your copay and coinsurance. However, you should only send payments to the office after confirming what you owe and that you haven’t already paid for it.

Why didn’t my insurance cover my medical bill?

The most common reason health insurance claims get denied is that your policy doesn’t cover the service or your physician is out-of-network. Sometimes, the physician’s office won’t code the claim correctly, which can cost you.

Here are some steps you can take when your health insurance doesn’t cover your medical bills:

• Contact your doctor’s office and confirm the codes are correct. They will re-process your claim if they made mistakes.
• Contact your insurance company directly to appeal the claim. Keep detailed records of the phone call, then follow up with a written letter briefly describing the call. Ask for a written response from the company within 30 days.
• Contact your state insurance department. If you cannot get through to your insurance company, the insurance commissioner will let you know the next best steps to take.

To avoid health insurance claim denials, always check your policy and confirm coverage with your physician before agreeing to an appointment.

Read more: What is my health insurance policy number?

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What You Need to Know About Medical Insurance Billing

It’s important to know how to read your insurance and medical billing statements to better understand the amount you’re responsible for, if any.

Your physician will bill you directly for any outstanding balances. However, your insurance company may also send you an EOB explaining why it covered certain services and not others.

An EOB is not a bill, and you’re not responsible for all of the charges listed on an EOB, but not all insurance companies send them.

Not all doctors’ offices send statements when billing insurance. Depending on your insurance company and doctor’s office, you may receive health insurance notifications from one, both, or none.

It’s important to keep all EOBs and statements from your doctor’s office and insurance company. Keeping copies allows you to reconcile your records and track any amounts owed to your doctor.

By tracking your health care benefits, you can ensure you understand what is and isn’t covered and when you may owe money for medical services.

Case Studies: What shows up on a health insurance bill?

Case Study 1: Acme Insurance Company

John, an Acme Insurance Company policyholder, received a bill after undergoing a covered medical treatment. The bill provided a detailed breakdown of charges, including treatment costs and consultations. As John had not met his annual deductible, the bill indicated his responsibility to pay that amount.

The procedure required a copayment as per his plan, clearly specified in the bill. John also had coinsurance obligations, with the bill outlining his share of the overall cost and the corresponding payment. Additionally, he received an Explanation of Benefits (EOB) summarizing the services, coverage, and payment information from the insurance company.

Case Study 2: Global Insurance Group

Sarah, a Global Insurance Group policyholder, sought expert help. Her health insurance bill from this visit included the following information: The bill provided a summary of the service delivered, such as the specialist’s consultation charge and any additional diagnostic tests conducted. Because Sarah’s insurance covered specialist consultations, the charge reflected the part covered by her insurance.

Sarah’s bill detailed the out-of-pocket charges she needed to pay because she had not met her annual deductible. Sarah was compelled to pay a co-payment for specialist appointments by Global Insurance Group. The co-payment amount was indicated in the bill. The bill also included details about the consultation’s preauthorization, assuring that the service was covered under Sarah’s coverage.

Case Study 3: Horizon Health Insurance

Michael, a Horizon Health Insurance policyholder, underwent a covered medical operation. His health insurance bill included the surgery charges, such as the operating room fee, anesthesia costs, and surgeon’s fees. The bill specified charges not covered by his policy. Coordination of benefits between his employer and spouse’s insurance plans was indicated.

Pre- and post-procedure expenses, like lab tests, prescriptions, and follow-up consultations, were included. Michael also received a summary of Horizon Health Insurance payments, detailing coverage and the amount owed.

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