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TIPS |
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#1 |
It is well worth your time and effort
to read thoroughly and understand as much as you can from documents
provided to you by your Plan. This includes your Evidence of Coverage,
as well as other documents such as Member Handbooks, Provider
Directories, Newsletters, and any other material provided by your
plan. |
| #2 |
Know as much as you can about how your plan works
before you need to use it. It is most important to know beforehand
about such things as selecting a primary care provider, obtaining
referrals to specialists, copayment requirements, and access to
emergency care. Realize that your plan will probably not cover
all of your medical expenses, and that you may have to pay part
of the cost. |
| #3 |
Ask questions about anything that is
not clear, confusing, or that you do not understand. |
| #4 |
If you need assistance, talk with your
plan's representatives, your agent, your employer, or contact
the Office of the Managed Care Ombudsman. |
| #5 |
If a problem arises, you should first
contact your Managed Care Health Insurance Plan. Your evidence
of coverage contains a telephone number and mailing address for
your use in contacting the plan. Be sure to record the day you
call, the name of the person you speak with, the title of the
person you speak with, and a summary of the conversation. |
| #6 |
If you or your physician have difficulty
obtaining approval for medical care, or if you experience difficulty
with a claim, know what your rights are according to your particular
plan. |
| #7 |
Understand your right to appeal decisions
made by the plan that are not in your favor (an "adverse decision"),
and follow the instructions provided by your plan to appeal an
adverse decision. You need to familiarize yourself with the various
levels of appeals and grievance procedures that are available
to you directly through your plan. |
| #8 |
If you write a letter to your plan to
file an appeal or a grievance, document the facts that support
your case. Keep your letter business-like and clearly state why
you believe you are correct. Include any supporting documents
from you or your physician that support your appeal or grievance. |
| #9 |
Follow the time lines established by
your plan for filing any appeals, grievances or complaints. Record
the date you provide information to your plan, and be sure to
keep a copy of any letters you send to your plan. |
| #10 |
At any point in the process, you can
contact the Office of the Managed Care Ombudsman for assistance. |
