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Get Your Claim Paid: One State's Example

Pennsylvania's Act 68 is a state law that spells out how the claims process will work for managed care plans. Act 68 distinguishes between complaints (issues not related to a medical necessity) and grievances (issues of medical necessity).

The complaint procedure still begins with a two-step review at the company level. The grievance process includes the two-step review but adds an expedited review for urgent situation. And, the new law allows providers to pursue grievances.

For example, a physician could file a grievance if he or she wanted to provide treatment that the consumer's plan would not cover.

At the Health Department level, grievance appeals are now assigned on a rotating basis to a certified physician, licensed psychologist or group of physicians or psychologists for a decision. The Health Department will make certain they don't have a conflict of interest.

Before filing a claim, the National Association of Insurance Carriers suggests you review your policy or employee booklet carefully to make certain the service in question is covered.

In addition, follow any managed care rules, including pre-certification requirements and use of network providers. If you are uncertain whether a provider is in your network, call your managed care plan representative. (And obtain referrals if necessary.) Give claim forms to the provider, with your policy number and other identifying information.

According to the association of insurance carriers, when submitting your claim you should do the following:

  • Find out if your provider submits the claim or if you need to.
  • If you need to do it, review the information to be sure it is complete and correct.
  • File the claim as soon as you are billed by the provider.
  • Send the claim to the correct address.
  • Keep a copy of all documents for your records.
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