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Appeals and Complaints

Part of choosing a health insurance plan should be making sure you have researched the company and are aware of the potential disadvantages. One way of discovering this is to view the number of complaints filed against each carrier. It is also important to know how to file a complaint or appeal for yourself if something dissatisfying arises with your personal health plan.

At times, you may have misunderstood your policy or an error occurred in the claims process, and your claim has been denied. Filing an appeal can be simple, though you must be prepared for a wait while it gets sorted out. Most insurers have a section on their website designated for appeals, and if not, use the customer service contact information.

If the appeal has not proven effective on your end when dealing with your insurer, you may ask the Oklahoma Insurance Department to intervene. Though they cannot act as a legal representative, the OID will give your claim an additional push to be handled appropriately if, indeed, your policy does cover the benefit for which you were denied coverage.

 

Contact Your Health Insurance Company

All carriers have trained staff who know how to handle appeals. Always try working through your issue with your carrier first before you seek additional help. Visit your company’s website or call the number on the back of your ID card for member services to begin the appeals process, or make sure you understand the situation by speaking with an agent before proceeding.

 

Aetna Appeals & Complaints

Blue Cross & Blue Shield of Oklahoma Customer Service

Coventry One Appeals & Complaints

Humana One Appeals & Complaints

UnitedHealthOne Member Services

 

Contact the Oklahoma Insurance Department

If working on your appeal with your health plan has been unsuccessful, you have the right to contact the Oklahoma Insurance Department and repeat the process all over again. However, the OID will help clear any communication barriers, such as if you have misunderstood your benefits, or if the company is not being compliant. Or, if you have a separate issue apart from a claim denial to take up with your insurer, the OID can also offer assistance.

Mostly, the OID encourages the policyholder to review their health plan before filing a complaint. If you have already done so, and are aware of your contractual obligation and payment schedule, and are certain the error was not on your end, you may file an appeal with the OID. The Department will send a copy of your complaint to your carrier, and try to resolve the problem. Other suggestions they offer in the complaint process include keeping detailed records or files, preferably electronically.

When the Oklahoma Insurance Department is responsible for an appeal, the external review process may take place. A new law in the state allows the use of health insurance experts from an Independent Review Organization (IRO) who are not connected to your insurer to examine your case from an outside perspective. The representative working on your case will determine if you qualify for an external review and assign you an IRO. IROs are certified nationally and by the OID.

Find out more about filing complaints and external reviews through the Oklahoma Insurance Department.

File an appeal online.

 

 

Sources:

 

1. Oklahoma Insurance Department. “Claims Process.” http://www.ok.gov/oid/Consumers/Consumer_Assistance/Claims_Process.html.

2. Oklahoma Insurance Department. “External Reviews.” http://www.ok.gov/oid/Consumers/External_Review_Process/index.html.

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