Understanding the Difference Between a Bill and a Claim

Modified on Thu, 10 Jul at 11:34 AM

What Is a Medical Claim?

A medical claim is a request for payment that your healthcare provider sends to your insurance company after you receive services. It includes details like the procedures performed, diagnosis codes, provider information, and the total cost. The insurance company uses this information to determine how much of the cost they will pay according to your plan benefits.

Key points about claims:

Submitted by your provider to your insurance.
Reviewed by your insurance company to determine coverage.
Results in an Explanation of Benefits (EOB) sent to you outlining what was paid and what you may owe.

What Is a Medical Bill?

A medical bill is the statement you receive from your healthcare provider showing any balance due after your insurance company has processed your claim. This may include deductibles, copayments, coinsurance, or services not covered by your insurance.

Key points about bills:

Sent to you by your provider.
Reflects what you owe after insurance has paid their share.
May be due immediately or have a due date for payment.

What’s the Difference?

Feature	Claim	Bill
Who sends it?	Healthcare provider → Insurance company	Healthcare provider → You (the patient)
What is it for?	Request for payment from insurance	Statement of what you owe
What does it include?	Procedure codes, provider details, diagnosis	Final balance after insurance processing
When is it received?	After service, before or during EOB review	After claim is processed by insurance

Summary

In short, a claim is how your provider asks your insurance to cover the cost of your care. A bill is what you may still owe after your insurance company has processed that claim. Reviewing both documents carefully helps you avoid errors and ensures you only pay what’s truly necessary.

Have questions about a claim or bill? Log into your HealthLock Member Portal or reach out to Customer Care for help.