Questions about Coverage and Care

Member Services

All HMOs have member services departments that are designed to assist the plan’s members with a variety of questions about the plan. Questions can be simple—such as what is a member’s co-payment or benefit coverage—or more complex issues including concerns about a selected doctor and how to change providers, the coordination of benefits if both a husband and wife have health coverage through their employers, or the process for appealing a decision made by the doctor or the health plan.

The member services department should be the first place to turn with questions, concerns or problems. The phone number is in your member handbook or on your identification card. Many issues can be easily and quickly resolved. If you are not satisfied with the resolution, you may also file a formal complaint with the plan.

Issues that cannot be resolved by the member services department generally fall into two categories: grievances or utilization review (UR) appeals.

Grievances have to do with non-medical, contractual issues. Utilization review appeals are when a consumer requests that a health plan reconsider its decision to refuse coverage of a medical service based on medical necessity.

Grievance Procedures

While the health plan member services departments may resolve many issues, if you are not satisfied with the resolution, or if you think the issue is not being resolved quickly enough, you may also file a formal “grievance with the plan.”

Every plan must have a grievance and appeals procedure to handle non-medical issues. This includes complaints related to billing problems, benefit coverage issues and issues regarding dissatisfaction with providers or quality of care provided. Some grievances can be filed over the phone, while others must be filed in writing. The health plan will tell you how to file a grievance and what your rights are in the grievance process.

Patients may also have questions relating to the denial of a specific medical treatment, even though the type of treatment may be covered (for example, a plan’s benefits may provide for treatment of cancer, but not stage-one clinical trials). These types of questions are considered utilization review decisions. Your rights concerning decisions on medical issues are covered in more detail in the “utilization review standards” and the Independent External Appeal sections.

For non-medical, contractual issues, every plan’s grievance procedure must include:

The following criteria apply to the appeals of grievance determinations:

Utilization Review Standards

Utilization Review (UR) is a process by which a health plan assesses the medical necessity or appropriateness of health care treatments. These reviews can take place prior to the proposed treatment, during treatment or after the treatment. All plans performing UR are required to:

Greater detail on all of these requirements is provided in every member’s contract and handbook.

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