When an appointment is billed to insurance, we send a claim to your insurance. Your insurance decides what it pays and what you owe, then sends you an explanation of benefits (EOB). Your Circle Medical invoice is the amount your insurance says you owe.
Looking for something else?
When your card is charged, and which cards we accept: How payments and billing work
Open or download an invoice: How to view and download your invoices
Get money back for a self-pay appointment: How to get an itemized bill (superbill) for reimbursement
What a self-pay appointment costs: Appointment costs
What happens after an appointment billed to insurance?
Your provider finishes their notes.
We send a claim to your insurance.
Your insurance processes the claim. This usually takes 4 to 6 weeks.
Your insurance sends you an EOB.
We send your invoice for the amount your insurance says you owe.
To see when your card is charged, read How payments and billing work.
What is an EOB?
An EOB is a summary from your insurance. It shows how your insurance handled the claim. An EOB is not an invoice, and you don't pay it.
Each insurance labels its EOB a little differently. Look for these lines, or the names in brackets.
What you'll see | What it means |
Claim number | The number your insurance uses for this claim. Have it ready if you call your insurance. |
Date of service and provider | The date of your appointment and the provider you saw. |
Service and procedure code (for example, "Office visit, 99213") | The type of appointment and its procedure code. |
Amount billed (Provider charges, Billed amount) | Circle Medical's full charge, before any insurance discount. |
Discount (Adjustment, Network savings) | The part of the amount billed that your insurance doesn't pay, based on its agreed rate with Circle Medical. You don't pay this either. |
Allowed amount (Plan allowance, Approved amount) | The most your plan pays for this appointment. Your deductible, copay, and coinsurance are based on this number. |
Deductible, copay, and coinsurance | The parts of the allowed amount you pay, listed separately. |
Not covered | Any amount your plan doesn't cover. The reason is usually given in a remark code. |
Plan paid (Amount paid) | What your insurance paid Circle Medical. |
What you owe (Patient responsibility, Your share) | Your deductible, copay, coinsurance, and anything not covered, added together. This should match your Circle Medical invoice for this appointment. |
Remark codes (Reason codes, Notes) | Short codes that explain an adjustment or a denial. Look for their meaning on the EOB itself. |
What to do next: compare your EOB with your invoice in the Billing tab.
Why is my charge higher than I expected?
Your insurance sets this amount. Circle Medical sends a claim, and your insurance applies your benefits to it. Your invoice is the amount on your EOB.
How your benefits set what you owe
Your insurance starts from the allowed amount, the rate it agreed to for this appointment. It then applies your benefits, usually in this order:
Deductible. Until you meet it, you pay the allowed amount yourself. Other care this year counts toward the same deductible, including care from other providers. Many plans reset it at the start of the plan year, so your first appointments of the year often cost more.
Copay or coinsurance. After the deductible, you pay a set copay or a percentage of the allowed amount. A video appointment can fall under a different benefit than an in-person one.
Out-of-pocket maximum. After you reach it, your insurance pays the allowed amount for covered care.
Plans apply these differently. Your EOB shows the calculation for this appointment. Check the allowed amount, how much went to your deductible, any copay or coinsurance, and the amount you owe. That last line may say "patient responsibility." It should match your invoice.
Example
The allowed amount for an appointment is $150.
If you haven't met your deductible, you owe $150.
If you've met it and your coinsurance is 20%, you owe $30.
If your plan uses a $25 copay for this appointment, you owe $25.
An estimate before your appointment can differ from this. Your insurance calculates the final amount only after it processes the claim.
What to do next
Call the member services number on your insurance card with your EOB in front of you. Ask:
What is the allowed amount for this claim?
How much was applied to my deductible, and how much of my deductible is left?
Did a copay or coinsurance apply, and why?
Is a video appointment covered the same way as an in-person appointment?
Have I reached my out-of-pocket maximum?
Write down the representative's name and the call reference number.
Reach out to support only if the amount you owe on your EOB doesn't match your invoice. Include both documents. If they match, the amount came from your insurance, and our support team can't change it.
Full definitions of each term are in Understanding your insurance benefits and what you might owe.
Why was this appointment billed differently from my last one?
Two kinds of codes go on every claim:
Diagnosis codes (ICD-10) describe the reason for the appointment, based on your provider's notes. For example, Z00.00 is a code for a routine adult wellness exam.
Procedure codes (CPT) describe the type and length of the appointment. For example, 99213 is a common code for an appointment with a returning patient. Medical coders assign these from the appointment notes. Your provider doesn't choose them.
Your insurance prices the claim from the procedure code, so a different code can mean a different allowed amount. An intake appointment or a wellness exam is usually coded differently from a follow-up. A longer appointment, or one where new concerns were discussed, can be coded differently too.
Codes aren't changed on request. A coder can only assign what the notes support.
Procedure codes are on your EOB. Diagnosis codes are on your itemized bill; see How to get an itemized bill (superbill) for reimbursement.
Why was my claim denied?
A denial means your insurance decided not to pay all or part of this appointment. A denial does not always mean you owe the full cost. Many denials are caused by a detail we can correct and send again.
What Circle Medical does after a denial
We review the denial your insurance sent us.
If the claim can be corrected, we correct it and send it again.
If your insurance needs something from you, we contact you and give you time to respond.
If the denial cannot be corrected, or you do not respond in time, we bill you for the self-pay amount and send you an invoice.
We do not charge you while we are still working on a denial that can be corrected.
Common denial reasons and what happens next
Reason | What happens next |
Your details don't match your insurance, such as a member ID, name, or date of birth | We correct what we can and send the claim again. We may ask you to confirm your details. See Trouble verifying your insurance. |
Your plan was not active on the appointment date, or it has ended | We contact you to update your insurance. If you do not update it within 48 hours, the appointment is billed to you as self-pay. If your plan was active on the date of the visit, reach out to support. |
Your insurance needs to know which plan pays first because you have more than one plan (coordination of benefits) | We contact you with what your insurance needs. If it is not completed within 48 hours, the appointment is billed to you as self-pay. |
Your plan requires a referral or prior authorization that we do not have | We ask you for the authorization number. If you do not send it or get the authorization, the appointment is billed to you as self-pay. See How to get your HMO referral or student health plan authorization. |
Your plan does not cover this service, such as a video appointment or this appointment type | We cannot correct this as we do not control your insurance benefits. You are billed at the self-pay rate. |
You have reached your plan's maximum benefit | You are billed at the self-pay rate. |
What you owe
If your insurance processes the claim, you owe the amount your insurance says you owe. That amount is on your EOB and matches your invoice.
If the appointment is billed to you as self-pay, you owe the self-pay price for that appointment type. See Appointment costs.
We send your invoice once your insurance has processed the claim, or once the appointment is billed to you as self-pay. Your card on file is charged as described in How payments and billing work.
What you can do
Ask us to review the claim. Reach out to support. Include the date of the appointment, and your EOB or denial letter if you have one. We can check whether the claim and may be able to resubmit.
Ask your insurance to review its decision. Only your insurance can change what it covers. Call the member services number on your card and ask why the claim was denied. Ask about an appeal if you disagree. Write down the representative's name and the call reference number.
Reply quickly when we contact you. Updating your insurance, completing coordination of benefits, or sending an authorization number within 48 hours help keep the appointment billed to your insurance.
Can I get an itemized bill?
Yes, after your appointment is complete and the invoice is paid. See How to get an itemized bill (superbill) for reimbursement.
What if I get a bill from a lab or pharmacy?
Circle Medical only bills for your appointment with your provider. Labs, like Quest or Labcorp, and pharmacies bill you directly. Contact them with questions about their charges.
Prescription coverage is between your pharmacy and your insurance. It may be covered even if we don't accept your insurance for appointments.
Still have questions?
Our support team can't see your plan's benefits. For coverage questions, call your insurance. For questions about your Circle Medical invoice, start a chat on the mobile app or web portal.