Bills and insurance
Medical claim form and superbill explainer
A claim form describes a visit almost entirely in codes: one set for the reason you were seen, another for what was done, and two-character add-ons that adjust their meaning. A superbill carries the same information on a receipt you can send to your insurer yourself. Add yours below to see each code line turned into words.
Explain your medical claim form and superbill
- 1. Add itDrop a PDF, take a photo or paste the text.
- 2. Check itPersonal details are removed on your device. You approve what is sent.
- 3. Read itSummary, table of results, terms and questions to ask.
The explainer opens on its own page with no adverts and no outside scripts. Your file is read on your device and is never uploaded.
What you get
- Each service line with its procedure code, modifier, units and charge as printed.
- Diagnosis codes listed with the descriptions given on the form, and the pointer showing which diagnosis each service is linked to.
- Place of service codes, modifiers and provider identifiers explained as fields.
- Questions to ask the provider's billing office or your insurer about any line.
Codes and fields on a claim form
- CPT codeA code, usually five digits, for a service or procedure performed by a clinician
- HCPCS Level II codeA letter followed by four digits, used for supplies, equipment, some drugs and other items
- ICD-10 codeA letter followed by digits, often with a decimal point, recording a diagnosis or reason for the visit
- ModifierA two-character code added to a procedure code to give extra detail about how or where the service was provided
- Place of service (POS)A two-digit code for the setting, such as an office or an outpatient hospital department
- UnitsHow many times a service was provided, or how many measured amounts of a supply or drug
- Diagnosis pointerA letter or number linking each service line to one of the diagnoses listed above it
What this tool cannot tell you
MedicDecode explains what the fields and codes on the form are for. It cannot confirm that a code matches the care you received, that a modifier was applied properly or that a charge is reasonable, and it does not give legal or financial advice. Code descriptions are restated from the wording on your form where there is any, because the official code sets are long and are revised regularly. Questions about why a code was chosen go to the provider's billing office, and questions about how a claim was processed go to your insurer.
Common questions
What is the difference between a claim form and a superbill?
A claim form is what a provider sends to an insurer to request payment; in the United States the standard form for professional services is the CMS-1500. A superbill is an itemized receipt carrying the same codes that the provider gives to you, typically so you can file the claim yourself. Neither one shows what the insurer decided.
Why is there a diagnosis code for something nobody told me I have?
Diagnosis codes record the reason for each service in a fixed vocabulary, and the official wording of a code can sound different from what was said in the room. Some codes describe symptoms or reasons for a visit and not a confirmed condition. If a code does not match your understanding, ask the provider's office what it refers to.
What do the two-character modifiers beside a code mean?
A modifier tells the insurer something extra about the service on that line, for example that it was separate from another service on the same day, or which side of the body was involved. The explanation identifies modifiers and restates any description printed with them. For the exact meaning of one on your form, ask the billing office.
Words you may see on this report
Tap a word for its plain-English meaning, an example line and what it does not mean.
- CPT Code
A CPT code is a five-character code that describes a medical service or procedure, used on bills and insurance claims in the United States.
- ICD-10 Code
An ICD-10 code is a letter-and-number code that describes a diagnosis, symptom or reason for care on medical records and bills.
- Coinsurance
Coinsurance is the percentage of a covered health care cost you pay after meeting your deductible, such as 20 percent of the allowed amount.
- Copay
A copay is a fixed amount you pay for a covered health service or prescription, such as a set fee for each doctor visit.
- Deductible
A deductible is the amount you pay for covered health care each year before your insurance starts paying its share.
- Explanation of Benefits (EOB)
An explanation of benefits (EOB) is a statement from your insurer showing what was billed, what the plan paid and what you may owe for a claim.
- In-Network
In-network means a doctor, hospital or pharmacy has a contract with your insurance plan to provide care at agreed prices.
- Out-of-Pocket Maximum
The out-of-pocket maximum is the most you pay for covered, in-network care in a plan year; after that, the plan pays 100 percent of covered services.
- Prior Authorization
Prior authorization is approval your insurer must give before certain treatments, tests or medicines are covered.