A Claim is a Request for Payment
Your healthcare provider typically submits to AZ Blue after you receive medical services. The claim tells us what services were provided, when they were provided, and how much they cost. If you receive care from an out‑of‑network provider and they do not file a claim, you’ll need to submit a claim.
The Claim Process
You Get Care
You visit a doctor or hospital for medical care.
Claim Sent
Your doctor sends the list of services provided.
Processed
We review your claim based on your plan benefits, then pay covered services and apply them to your deductible, copays, or coinsurance.
Explanation of Benefits (EOB)
You can view payment details and any amount owed to your provider here.
Timeline - Important things to keep in mind
- Claims typically get sent in 1 - 15 days. Providers have up to 3 months to submit.
- Claims are typically processed in a week or two. It may take up to 30 days.
- The Explanation of Benefits (EOB) is available in your portal digitally after it is processed.
Claim Status Explanations
What each claim status means for you.
| Pending |
We've received your claim and are checking your plan details. This is normal and typically happens in about 30 days. We are checking if your plan covers the care or if we need more information. |
| Processed |
Your claim is done. You'll receive an Explanation of Benefits (EOB) with all the details in your portal, or if you selected, by mail. |
| Denied |
A claim can be denied for reasons other than coverage, such as missing information from the doctor, a duplicate claim, an out-of-network provider, or missing coordination of benefits information. |
Example of How Cost Sharing Works
Example of $150 allowed amount charged for an in-network doctor visit
- Doctor visit before deductible is met
You pay the full allowed amount billed to you
$150
This amount is counted towards your deductible - Doctor visit after deductible is met
You pay 20% coinsurance of the allowed amount
$30
This amount is counted towards your out-of-pocket maximum - After reaching out-of-pocket max
AZ Blue pays 100% of the allowed amount
$0
No cost sharing applies
This example does not consider your actual benefits. To view benefits for your plan, click here.