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Appeals and Complaints


As an insured Missourian, you may find your health insurance coverage is not always what you want it to be. Whether the issue is a denied claim for a service you believed to be covered, or with a particular agent or the company itself, there are ways to handle your problem properly. Claims are often denied by mistake, as there could have been a different code for the type of service you used, and the provider billed it incorrectly to the insurer. Companies have been working to increase the simplicity of claims processing, and communicating clearly so you are able to look at your benefits and be aware of what your plan covers. In some cases, it may not be so clear.

Regardless of the issue, it can be resolved. Every insurer has a department dedicated to helping their members, as well as a claims department. In such an event, the first action to take is to contact your health plan and discuss the matter with them. If you do not feel your issue has been taken care of, you may go to the next level and contact the Missouri Department of Insurance, who will help you better communicate with your insurer.

 

Contact Your Health Insurance Company

In most cases, the phone number for your health plan’s customer service department is printed on your member ID. However, certain insurers have begun the claims appeal or complaint process by creating an easy online form. Most Missouri health insurance companies have provided instructions for the process through their websites.

 

Aetna Appeals & Complaints

Anthem Appeals & Complaints

Blue Cross and Blue Shield of Kansas City

888-989-8842 or 816-395-3558

Coventry One Kansas Appeals & Complaints

Coventry One Missouri Appeals & Complaints

Humana One Appeals & Complaints

UnitedHealthOne Member Services

800-657-8205

 

Contact the Missouri Department of Insurance

In the case that you are unable to resolve a problem directly with your insurance company, or have a complaint to report regarding a company representative or suspicious practice, you may be able to work with the DOI. The DOI cannot substitute for a lawyer, but they can act as a middle man to help you communicate with your insurer. The Division of Consumer Affairs can clear up confusion by informing you of your options as a policyholder in how to address a problem with your insurer.

The Division is able to discuss your issue with the insurance company, and require them to respond or explain their end. If the company is not complying with Missouri insurance laws, they will be asked to take corrective action by the Department of Insurance. You will also review your health insurance plan to make sure you understand what is covered and what is excluded. They can also assist in filing first and second level grievances and appeals. They also can use an external review to handle issues with your insurance company. The Missouri Department of Insurance can help those with private health plans only.

To file a complaint with the Division, you may fill out a form online.

You may also print the form and mail it to the Division.

 

Missouri Health Insurance Complaints 2011

 

Below are the reports for complaints filed against the top health insurers, provided by the Department of Insurance. A complaint index of 100 is considered normal, and less than 99 shows the company has received a lower than average number of complaints. This number is arrived at by comparing the ratio of complaints to the amount of premium sales to the rest of the industry. These numbers reflect the years 2009-2011 for each company. Selected here are only the carriers offered by East Coast Health Insurance in Missouri.

Anthem clearly has the least amount of complaints, with a solid zero, though they take up a minimal portion of the market. While Blue Cross and Blue Shield of Kansas City is the market leader, they have a very low number of complaints in proportion to their exceptional amount of members.

For the full report, visit the Missouri Department of Insurance.

 

 

 

 

Sources:

 

1. Missouri Department of Insurance. “Insurance Complaints”. http://insurance.mo.gov/consumers/complaints/index.php.

2. Missouri Department of Insurance. “Complaint Index”. http://insurance.mo.gov/consumers/complaints/compindx.php.

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