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Health Insurance Tips
- Review your health insurance policy and make sure you understand coverage restrictions and exclusions. For example, health insurance typically excludes most dental benefits. Understand that if you have a medical condition that results in damage to your teeth, while the medical condition may be covered, dentistry to restore your damaged teeth may not be.
- Understand your responsibilities under your health plan. Have you selected a primary care provider (PCP)? Do you need a referral from your primary care provider for services and procedures your PCP cannot provide? Have you received written confirmation that a requested referral has been approved, or, if you need authorization before a written notice has time to get to you, have you called your insurer to make sure they have authorized the referral? Have you confirmed with your insurer that the services your PCP has made a referral for are services covered by your health plan? For example, your PCP may refer you for infertility treatment, but if your policy doesn’t cover infertility treatment there are no benefits available. Do not assume that if you request a referral from your PCP the insurer will pay for the referred services!
- Keep your insurance ID card handy. Don’t hesitate to pick up the phone and call the number on your insurance ID card for assistance in understanding any part of your policy you don’t understand. Call your insurer if you get a bill, a referral, an explanation of benefits form or other document you don’t understand. Other sources of assistance include your insurance agent and your human resources department if your employer provides your health insurance. The Bureau is always available to assist as well, and can be reached from 8:00 A.M-5:00 P.M. through our in-state 800 #, 1-800-300-5000.
- Keep good files. Know where to find your policy or benefits booklet. Keep copies of any health insurance related documents you receive from your insurer, agent, human resources department or health care provider in a file you can easily locate. If you call your insurer, agent, human resources department or health care provider regarding an insurance issue, keep a pad of paper handy. Ask for the name of the person you are talking to and make a note of what you discussed, being sure to indicate the date and time of your call.
- Know your rights. You have a right to receive a response to a request for authorization of services within two working days. If your insurer denies a requested service on the grounds that the requested service is not medically necessary, your insurer must send both you and your provider a written notice explaining why it believes the requested service is not medically necessary. The notice must advise you of your right to obtain any clinical criteria or information relied upon by the insurer in reaching its decision. The notice must also advise you of your right to appeal the decision. By law you are entitled to appeal any health insurer decision you disagree with (not just medical necessity coverage denials). If you lose your appeal, your insurer must sent you a written notice identifying the names and credentials of the persons who made the decision and explaining the reasons for the decision. You have the right to the information relied upon by your insurer in arriving at their decision. You have the right to a second level appeal. You have a right to attend and be represented at any second level appeal. If you are not satisfied, you have the right to complain to the Bureau of Insurance.
If you have any questions or need assistance, don’t hesitate to call the Bureau of Insurance. We can be reached from 8:00 A.M-5:00 P.M. through our in-state 800# at 1-800-300-5000, or (207) 624-8475. Consumer brochures, complaint forms and other information are also available on the Bureau’s website at: www.maine.gov/pfr/insurance
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August 12, 2013