What Happens After I Get Care?

After you go to the doctor, how does the doctor get paid? How do you know if your visit was covered? What if you owe more for the service? We can help make sense of what happens next.

A Claim's Journey

After You Go to the Doctor

  1. You get care from your doctor, hospital, or clinic
  2. If you have a copayment or are still meeting your deductible, you can pay this now, before you leave the doctor's office from getting care.
  3. The doctor who gave you care sends us a claim, which just gives us the details of the service you received and asks us to pay for the cost about your copayment or coinsurance
  4. We process that claim based on your plan's benefits.
  5. You'll get an Explanation of Benefits (EOB) in the mail, explaining what we paid and if you still owe anything. If you have coinsurance, you'll pay this now, after your claim's been processed.

How Claims Get Processed

After your doctor sends us a claim, we check it against your plan's benefits:

  • We check if the care you got is covered by your plan.
  • If it's not, we check to see if there was a preauthorization for the service before you got it. (A preauthorization is a review process your doctor must request for a drug or service that's not covered by your plan before you get it. It helps us make sure that it's medically necessary for you to receive that service.)
  • Then, we make sure that we have all of the details we need from the doctor to process your claim.

Once we have all of this information, we also look at the costs, which can vary based on the type of service you get and your plan's benefits, and figure out:

  • How much of a service's cost we'll cover
  • How much of that cost we'll pay for the service in this case, based on your plan and deductible
  • How much of that cost you must pay for

Once we've done all that, we either approve the claim, pay you or your doctor, and send you an EOB, or we deny the claim. Sometimes, your doctor may just have to resubmit the claim with more information. But if the service isn't covered or wasn't preapproved when it should've been, you can either pay your doctor yourself or appeal our decision.

Learn more about filing an appeal and our Utilization Management Procedures, which let us review coverage of certain services to make sure you're getting the right care at the right time.

What Is an EOB?

The EOB you get from us after getting care breaks down the details of the claim and the costs. It shows:

  • Services the doctor's office claimed
  • Total costs from the doctor's office for those services
  • Any discounts that we have set up with your doctors
  • How much of your deductible applies to those services
  • The copay or coinsurance you paid or will pay for those services
  • Any costs that weren't covered by your plan and why they weren't covered
  • How much was paid by other insurance plans you might have
  • How much we paid
  • How much you still have to pay for those services

The EOB isn't a bill, only an explanation. You will get a separate bill from your doctor's office.

Check your claims, EOBs, and authorizations anytime, anywhere on Your Health Alliance.