Kids and Health Care: If You Have Trouble Making a Claim Conclusion

There are several important steps you can take to improve the chances that your health insurance claims will go smoothly:

• Never rely on what you think is true about benefits or providers covered under your plan -- even if they are stated in your most recent benefits handbook. Check whether the benefits, services or providers you need are covered under your plan before you receive treatment.
• Call your plan's customer service department, and remember to take notes. Get the representative's name and write it down, along with the date, time and general substance of your conversation.
• If a claim problem arises and you need to file a grievance, these notes will come in handy. Most insurers' customer service phone calls are recorded. So, having the date and time of your call will make locating your call history with the representative much easier.
• Should you have a problem with a claim, call the insurer and ask for an explanation. Again, remember to take detailed notes.
• If the explanation is not consistent with your understanding of your health benefits, call or visit the person in your company responsible for benefits administration. Because of their position, they might be able to quickly resolve your problem.
• If you have a claim problem that's unresolved, file a grievance with your health plan. If you get a denial, don't give up. In many states, the complaint eventually goes before a grievance committee that's outside the plan. There's always a chance the denial might be reversed. You might also want to complain to the officials who regulate your health plan.

Remember: If your health plan is self-funded by your employer, it is regulated by the U.S. Department of Labor. Otherwise, your health plan is regulated by your state's insurance department. Your state has a complaint procedure that will trigger an investigation into your problem.

• If you discover your plan providers or benefits have changed, and you have not been notified, bring it to the attention of the person in your company responsible for benefits administration. Ask if this situation is covered under the company's contract with your health plan.

When it comes to solving health insurance disputes, you are your child's best advocate. But standing up for your rights requires understanding your policy, keeping careful records and following procedures, including appeals to the proper state and federal agencies.