Certified Application Counselor Practice Test

What is a claim in health insurance?

1. A summary of covered services received

2. A request for payment submitted to an insurance company

3. A notification of payment received from an insurer

4. An explanation of benefits issued by the provider

The correct answer is: A request for payment submitted to an insurance company

A claim in health insurance refers to a request for payment that is submitted to an insurance company after a policyholder receives medical services. This process allows healthcare providers or policyholders to seek reimbursement for the costs incurred during medical treatment. When a claim is filed, insurance companies review the claim based on the policyholder's coverage, the medical procedures performed, and other relevant information before deciding on payment. Understanding this concept is essential, as it plays a vital role in the reimbursement process for both patients and healthcare providers. The claim serves as the formal request for funds, documenting the services provided and the costs associated with them. Once a claim is approved, it can lead to payment directly to the provider or to the policyholder, depending on the circumstances. This clear process ensures that medical services are adequately compensated, thereby supporting the financial sustainability of healthcare services. In contrast, other options describe different components related to health insurance transactions but do not define what a claim is. For instance, a summary of covered services received would reflect services utilized but not the request process for payment; a notification of payment received pertains to the outcomes of claims but doesn't represent the initial request; and an explanation of benefits issued by the provider outlines details of coverage but is not the claim itself.