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Talking to Government Agencies for Health Insurance Claim Help

Part 1: The Basic Tools, Chapter 3: Developing a Systematic Approach to Dealing with Health Insurance Page 19

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Your request for help should probably be addressed to a state agency rather than to a federal agency if the problem has to do with the way in which a traditional individual or group insurer or a managed care program

  • has processed a claim;
  • has determined the level of reimbursement in reference to a claim;
  • has interpreted a specific state law or regulation or a health insurance policy rule in a manner with which you disagree.

On the state level, you can write to your state Department of Insurance or Department of Health for help. Although the structure differs from state to state, in some states the Department of Insurance deals with situations related to traditional insurers while the Department of Health deals with situations related to managed care plans or hospitals. Some states also have separate insurance boards that deal with specific aspects of health insurance, such as individual or small employer insurance plans. Check with your state Department of Insurance to determine the specific structure in your state.

In some areas, the local county or state medical society may also help solve specific health insurance claim problems related to medical bills from doctors, testing centers, or hospitals. Check with your county or state medical society to determine if a program exists in your area. (See Chapter 6 for a further discussion of claim appeals related to self-funded plans. See Chapter 7 for a further discussion of claim appeals related to managed care plans.)

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