Dealing with Government Agencies Regarding Managed Health Care Insurance Issues
Part 2, Chapter 7: Managed-Care Plans Page 10
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You might then explain why you think the plan's decision was incorrect. Cite specific sections of the policy or other evidence that supports your point of view.
If a supervisor or executive responds with a letter or a telephone call, it's important to remain calm and polite at each stage of the process and to explain the problem as simply and as clearly as possible. If you're feeling angry or upset about the way your claim has been handled, wait until you're feeling calmer before discussing the issue.
If your letter does not resolve the problem, the next step is to write to your state Department of Insurance or Department of Health and ask for their help. Although the structure differs from state to state, one or both of those state agencies are generally responsible for implementing state health insurance laws and regulations that deal with managed care plans in a particular state. If that does not result in a resolution of the problem, you can also write to the American Association of Health Plans (AAHP) -- a national organization that represents Health Maintenance Organizations and other types of man aged care plans -- or to the National Committee for Quality Assurance (NCQA), the organization involved in reviewing HMOs for possible accreditation (See Appendix B). Both the American Association of Health Plans and the National Committee for Quality Assurance have programs that are designed to help consumers solve problems related to HMOs or to other managed care organizations.
There are other organizations and agencies that may be able to offer help and advice, as well, particularly if the problem relates to a child with a disability (See Appendix B). In addition, you can also discuss the problem with an attorney.
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