FAQ

There are many things you can do to improve your situation, but you will have to pay some of your medical expenses. First of all, if you have insurance, review your member handbook, noting what is and isn’t covered. Budget for your share of the expenses you know you will have and try to anticipate expenses you may face. Identify your family’s needs, which may include medications, allergy treatments, physical therapy, well-child examinations, immunizations, etc.

You can also do the following:

• Review the coverage and benefit limits for each type of treatment. Find out if they require preauthorization or a referral to a specialist.
• Read the grievance explanation in your member handbook and know your rights.
• Talk to your insurance company’s customer-service department if you have questions.
• Determine whether you need more insurance and set aside money to pay additional premiums.

If you have a doctor now, and you are satisfied with the level of care, call your plan to find out if he or she can be your PCP. If you don’t have a doctor or aren’t satisfied with your care, ask for a list of participating doctors from your insurance company. Tell friends, co-workers, and neighbors you’re looking for a new doctor, and ask for recommendations. Contact the state medical society and hospitals for lists of physicians accepting new patients in your area. Find out if any of these doctors participate with your insurance company. Find out which doctors are convenient to where you live and work.

Call the physician’s office to verify that the physician will accept you as a patient. Talk to the receptionist about office policies. Find out office hours, how emergencies are handled, how long it will take to schedule an appointment, and which hospitals the doctor uses.

Once you have selected a physician, notify your insurance company.

A good way to get established with your new primary-care provider is to schedule a physical examination. Make sure the examination is covered by your insurance company or plan to pay for it yourself.

You can change your PCP. Notify your insurance carrier of the change. An insurance company may limit changes to two selections in a 12-month period. Refer to your member handbook or call customer service for additional guidelines.

You may select a participating OB/GYN as your PCP if he or she contracts with your insurance company to provide primary care.

You have the right to request a copy of the utilization-review policy and procedures that your insurance company uses to determine medical necessity. You can file a grievance requesting reconsideration. Consult your doctor and submit important information with your grievance. Your insurance company must have a medical doctor determine whether a treatment is covered as a medical necessity.

You may not be allowed to go outside the clinic and have your medical bills covered. Tell your primary-care provider about all of your physical- and emotional-care needs, as he or she is responsible for arranging your health care while you are enrolled in the HMO or managed-care organization. If you are uncomfortable with your PCP or feel that she or he doesn’t listen to you, you may want to call the specialist’s office that has treated you to see which PCPs the specialist works with closely. Verify that the recommended provider is a participating provider in your HMO and see if he or she is accepting patients. Call your HMO and tell them you’ve switched PCPs.

Find out specifically why the claim was denied and be certain that the error was not on your part. Preauthorization is binding for 30 days. However, eligibility determinations are binding for five days unless the insurance company knows that coverage will end before then and a termination date is known. Exercise your grievance rights once you know why the claim was denied, if it was unjustified.