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
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:
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
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
you are covered through your employer AND your employer
self-insures your plan,
then your coverage is subject to federal
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
ERISA appeals procedure is available from the United States
Department of Labor.
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,
is available from ETF. In addition, you may be able to use Wisconsin's
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.
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.
you have Medicare coverage,
the federal Centers for Medicare and Medicaid Services (CMS) provides information
appeals and grievances as well as a listing
of helpful contacts to assist you in resolving your
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.
Document your contacts.
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.
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.
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.
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
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
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 forwards complaints on to plans - and plans
often then respond in the complainant's favor.
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.
If your problem is not resolved satisfactorily by the plan or OCI,
you can fight your case yourself in small claims court.
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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April 01, 2013