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What is a claim?

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Michigan Health Insurance - Customer Service - What is a claim?

If you go to a doctor who's not in your network, you may need to pay for the care you receive. In which case, you'll need to submit a claim to get reimbursed. Learn more about claims here.

Simply put, a claim is a request to be paid for a health care service.

When you visit your doctor for a check-up, your doctor submits a claim to your insurance company. Your insurance company reviews the claim, and if the care you received is covered by your plan, the insurance company approves the claim and then pays your doctor.

Submitting a claim

Normally, your health care professionals will take care of your claims. However, if you visit a doctor outside of your network, you may have to submit the claim yourself.

In those situations, you'll pay the full cost of the service. Then you'll submit a claim to us. We’ll reimburse you for the portion covered by your health care plan when we approve your claim.

You'll need separate claims for each type of service you want to be reimbursed for. Let's say you get sick and you decide to visit an out-of-network doctor. The doctor examines you and gives you two prescriptions. You pay the full cost of the doctor's visit before you leave. Then, you go to the pharmacy. You pay the full cost again when you pick up your prescriptions.

When you get home, you'll need to fill out two claims: one for the doctor's visit and one for the prescriptions. It's OK to have multiple prescriptions on the same claim because they came from the same pharmacy.

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