Online Insurance Guide

Insurance Claims

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What is a claim?

In order for an insurance company to reimburse your provider for the medical services you receive, either you or your health care provider must submit specific information to your insurance company. This information is referred to as a claim.

Who usually submits the claim?

For medical procedures or services:

The medical provider typically submits the claim. Your medical provider will need to fill out the appropriate claim form with patient demographic information, insurance information, descriptions of services and associated billing codes that describe the procedure or service as required by the insurance company, provider information and dates of service.

For prescription drugs:

Your pharmacy or specialty pharmacy provider will typically submit a claim to your insurance company. Claims submitted for prescription medications provided in outpatient pharmacies usually require a drug's specific National Drug Code (NDC) number and the name of the drug. NDC is a national classification system used to identify drugs.

If you are required to submit the claim form, your pharmacist can provide you with the NDC number that you should include on the claim form.

Will I ever be required to submit a claim?

If your plan requires that you pay for medical services up front and submit a claim for reimbursement, you will probably be required to submit your claim yourself.

How do I submit a claim?

Contact your insurance company to obtain information on how to file the claim correctly or to request the proper claim form. If filing a claim for a medical procedure/service or prescription drugs, many health plans require that you complete a claim form. Learn more

Contact us with insurance questions, success stories or suggestions.
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The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs. PHA does not endorse or recommend any commercial products or services.

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