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Having benefits and using benefits are two different skills. Plenty of people carry a card for years and still pay full price at the dentist, or let receipts pile up unclaimed in a drawer until they expire. None of that is necessary. Submitting a claim today takes about ninety seconds, and most of the time you won't pay up front at all.
Here's exactly how to use the plan you already have.
First: how the money actually reaches you
There are two ways a covered expense gets paid, and knowing which one applies saves you from fronting cash you don't need to.
Direct billing (the easy way)
Direct billing — sometimes called assignment of benefits — means the provider sends the claim straight to your insurer and only charges you the part the plan doesn't cover. You hand over your benefits card, the dentist's office submits electronically, and you pay your 20% (or whatever your co-insurance is) at the desk. Done.
Most dentists, many pharmacies, and a growing number of physio and massage clinics offer this. Always ask "do you direct bill to [your insurer]?" when you book — it's the difference between paying $40 and paying $200 and waiting for the rest back.
Pay-and-claim (the other way)
When a provider doesn't direct bill, you pay in full, then submit the claim yourself and get reimbursed — usually by direct deposit within a few business days. It's not hard; it's just an extra step.
How to submit a claim yourself
Almost every insurer now has an app and a member website. The flow is nearly identical everywhere:
- Log in to your insurer's app or member portal.
- Choose Submit a claim and pick the type (drug, dental, paramedical, vision).
- Enter the provider, date, and amount.
- Snap a photo of your receipt and attach it.
- Confirm your direct-deposit details and submit.
Michelle's tip: Set up direct deposit the day you enrol, and keep your receipts until the money lands. Take a clear photo of every receipt right away — a faded thermal receipt three weeks later is the single most common reason a claim stalls.
Reading your EOB without the dread
After a claim is processed you'll get an Explanation of Benefits (EOB). People panic at these because they look like bills. An EOB is not a bill. It's a receipt explaining what happened to your claim. You'll typically see:
| On your EOB | What it means |
|---|---|
| Submitted / charged | What the provider billed |
| Eligible amount | The part your plan recognizes (may be trimmed to "reasonable & customary") |
| Paid by plan | What the insurer actually paid |
| Your portion | Deductible + co-insurance you're responsible for |
| Explanation codes | Short notes explaining any reduction or denial |
If "paid by plan" is lower than you expected, the explanation code almost always tells you why — a maximum was reached, the deductible applied, or the charge exceeded the customary amount.
When a claim gets denied — what to do
A denial is usually fixable, not final. Work through it in order:
- Read the code. It often points to a simple cause — wrong date, missing receipt, or a service that needs pre-approval.
- Check the timing. Most plans have a claim deadline (commonly within 12–18 months, often by a set date the year after the expense). Don't sit on receipts.
- Look for prior authorization. Some drugs and services need pre-approval; submit that form and resubmit.
- Coordinate a second plan. Covered under a spouse's plan too? Submit the leftover to that plan to recover more (this is coordination of benefits).
- Still stuck? Call the member line — or your advisor. We resolve these all the time.
Don't leave money on the table
The most expensive mistakes are the quiet ones: not asking about direct billing, missing a claim deadline, or never claiming a benefit you forgot you had — like a portion of new glasses or a wellness account. You're paying for this coverage. Using it fully isn't greedy; it's the entire point.
