The process begins after a patient has a doctor visit, which could include actual treatment for injuries or other medical conditions. Sometimes the visit may simply be a diagnosis of a condition leading to a prescription given by a doctor. After the visit has concluded, a doctor will give details of the visit to a medical specialist of some sort. This specialist will fill out a billing record with more technical information regarding the visit, such as codes representing different diagnoses. The billing record is then sent to the insurance company, or sometimes to an intermediate firm that will process the record beforehand. Either way, the billing record will get processed and analyzed to make a determination on which charges the insurance company pays for. The insurance coverage of a patient may not actually cover all the costs of the services the provider has included in a billing record.

Once the insurance company or some other intermediate organization has finished processing the claim, deciding which costs it will cover and which ones the patient has the responsibility to pay, an explanation of benefits (EOB) is returned to the original provider of the medical service. Once the provider gets the EOB, the information and coding will need to be deciphered. The insurance company might possibly have agreed to pay for all the charges the provider listed on the bill. If so, the insurance provider pays on behalf of the patient.

However, insurance companies rarely cover all the costs a medical provider has listed on the bill. Usually one or more of the charges will be determined by the insurance company to be the responsibility of the patient. If the insurance company rejects charges the medical provider has listed, the provider must make changes to the claim and resubmit it to the insurance company. Once resubmitted the insurance company will look at it again to see if the information is accurate, and to determine whether it will pay the reduced charges the provider has listed.

Eventually, perhaps after several repetitions of this medical billing process, the claim will be accepted by the insurance company and it will pay for its portion of the charges, while the patient pays for the remainder.