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Glossary
A health insurance claim is essentially an invoice that your provider sends to your health insurance company for services you received.
The claim contains a line-by-line account of all the services you received and how much each one costs. Your insurer will process your claim before it issues an explanation of benefits (opens in new tab) to show you how the claim was handled and who pays what.
How do individual health insurance claims work?
There are several steps to the claims process:
How do I know how much I owe?
What you owe for your claim depends on which health care services you receive and how your plan shares the cost with you. The services on your claim will be covered-in-full, not covered or covered (opens in new tab). If you have a deductible (opens in new tab), you may be responsible for the bill, or you might share the cost with your insurer by paying either a flat fee, called a copay, or a percentage of the bill, called coinsurance. If you owe something, you'll be billed by the doctor's office, lab, or hospital directly.
What about claims from providers who aren't in the network?
Oscar is an Exclusive Provider Organization (EPO) (opens in new tab), which means that we do not cover out-of-network (opens in new tab) care (except in the case of an emergency, in which case we process the claim as if it was in-network, and members pay their usual cost-share). Visiting a doctor who isn't in the network when it's not an emergency is one reason a claim may not be covered.
To avoid having your claims denied, call us at 1-855-672-2755 before you get care. We can help you find a doctor in our network and answer questions about how your plan works.