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Consumer Guide to Health Care


How to Deal with Problems with your Health Insurance

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There are a number of things you can do to avoid problems with your health plan - but if you have a problem now, there are some steps you can take to solve your problem. Having a claim denied is just one of several types of problems that people run into with their health insurance coverage. If you encounter a problem getting the care you need or getting your health plan to pay for your care, then you should speak up and follow these steps:

  1. First of all, you need to find out what type of coverage you have. This will help you figure out what steps you can take to get your problem solved.

    • If you are covered through your employer AND your employer purchases insurance on your behalf from one or more plans, you should follow the steps outlined below. In addition, you may be able to use Wisconsin's independent review process.

    • If you are covered through your employer AND your employer self-insures your plan, then your coverage is subject to federal Employee Retirement Income Security Act (ERISA) (exit DHS) laws - NOT to state insurance laws. This means the Office of the Commissioner of Insurance has no jurisdiction over your plan, but you can still file a grievance with your employer or plan administrator. All the steps below, except for steps 9 and 10, apply to you. Additional information on ERISA appeals  procedure is available from the United States Department of Labor.

    • If you are a state employee, you can file a grievance with your plan as described below in steps 2-8. You can also contact the Department of Employee Trust Funds (ETF) ombudsman, who may be able to help resolve your problem. More information on requesting a review  (PDF, 26 KB) is available from ETF.  In addition, you may be able to use Wisconsin's independent review process.

    • If you are part of the Medicaid or BadgerCare program and are covered under a managed care plan, you can contact either your plan or the Division of Health Care Access and Accountability in the state's Department of Health Services, which runs Wisconsin Medicaid and BadgerCare programs. Each plan is required to have an HMO advocate whose role is to assist you.

    • If you are part of the Medicaid program and are covered under the traditional fee-for-service plan, you can contact the Division of Health Care Access and Accountability in the state's Department of Health Services, which runs the Wisconsin Medicaid program.

    • If you have Medicare coverage, the federal Centers for Medicare and Medicaid Services (CMS) provides information on appeals and grievances as well as a listing of helpful contacts  to assist you in resolving your problem.

  2. Contact the customer service department for your plan. If they promise you something over the phone, ask for it in writing. Keep track of who you speak to - their name, title, date and what was discussed. You can even ask the HMO to record your conversation.

  3. Document your contacts.

  4. If your problem is not resolved via telephone AND delay in solving your dispute could jeopardize your life or health, you should notify the plan of your concern in writing immediately, i.e., by fax (NOT by mail), so that an expedited grievance process can be followed. Your plan is required to resolve an expedited grievance within 72 hours of receiving it.

  5. If your problem is not resolved informally and there is no danger to your life and health, write the plan a letter explaining your concern. This is called filing a grievance. This letter should describe your problem, the steps you have taken to solve the problem, and how you would like to have the problem resolved. Include copies of any supporting documentation you have received from your doctor or from other medical personnel - and keep copies of all correspondence. In responding to your grievance, the plan is required under state law to follow certain steps. These steps are described below in steps #6, 7 and 8.

  6. Within 5 business days, the plan must deliver or put in the mail to you an acknowledgement of receiving your grievance. The plan will probably tell you when the next meeting of their grievance committee takes place. They must give you at least 7 days written notice of when and where the meeting will take place.

  7. You have a right to be present at the grievance meeting. If you choose not to attend, the committee will base its decision on the written material you submit. If you choose to attend the meeting, you may bring anyone with you such as a family member, friend, doctor or lawyer. This is an opportunity for you to explain your concern in person and to answer any follow-up questions the committee may have.

  8. A decision will probably be made soon after the grievance committee meeting, but the plan has up to 30 calendar days after receiving your grievance to resolve your concern. Alternatively, the committee can postpone a decision for another 30 calendar days if they feel they need more information before deciding. If they decide to postpone a decision, they must notify you in writing of the reason for the delay and when resolution of the grievance can be expected.

  9. In addition to filing a grievance with your plan, you can also file a complaint with the Insurance Commissioner's office. Call 800-236-8517 (or 800-947-3529 for the hearing or speech impaired) to get a complaint form, or write to the Office of the Commissioner of Insurance (OCI) at P.O. Box 7873, Madison, WI 53707-78773 or download one from the OCI website. OCI forwards complaints on to plans - and plans often then respond in the complainant's favor.

  10. Please note that OCI will not intervene in determining medical necessity or investigating quality of care. OCI maintains that only courts can resolve these types of disputes.

  11. If your problem is not resolved satisfactorily by the plan or OCI, you can fight your case yourself in small claims court.

  12. At any point in your dispute, you can choose to contact a lawyer. A lawyer may be able to contact the health plan without starting a lawsuit. Remember that lawsuits can be costly and stressful and still may not result in the problem being resolved in the manner you would like.

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Last Revised: April 01, 2013