
<b>Some Information on Working With Your Health Plan/Insurance Company</b> 
(from a dear friend in the industry) 

<b>Make sure that you have a current copy of your health insurance policy or Certificate of Coverage or Health Care Contract.  Don't rely on a policy or certificate that is more than one year old to have the most correct benefit information.</b>  Benefits change based on legislation, community standards, changing technology, etc.  If your policy is more than 12 months old, ask for a new policy. 

<b>Read your health insurance policy or Certificate of Coverage or Health Care Contract and make notes to ask questions about things that are unclear or confusing to you. </b>If you have coverage through your employer, find out if the group/account has a special customer service contact at the health plan/insurance company.  Use that special contact to walk you through any benefits that are confusing to you. 

<b>If you have coverage through your employer, find out if the employer has a special contact or expert that you can contact to discuss coverage/benefits and use as a benefit expert, or an advocate. </b>

<b>Pay attention to policy/contract exclusions.</b>  If a service or item is expressly excluded, discussion about the service or item with the health plan/insurance company may be academic. 

<b>Find out if the health plan/insurance company has a Case Management department or has a contract with a case management company. </b>  Find out what criteria the health plan/insurance company uses to identify potential case management patients/members/subscribers/enrollees/policy holders. If your health plan has a case management department, there should be well-defined "triggers" whereby the health plan identifies patients/members who would benefit from case management.  If you don't meet the criteria or triggers, ask if the health plan includes patients in case management that are unusual or require coordination of care that exceeds usual requirements. 

<b>Request a case manager. </b>It's o.k. to be your own advocate.  Be reasonable, rationale, persistent.  Be prepared to justify assignment of a case manager, if you have an unusual case.  Presentation of the clinical details of your case should be compelling - unusual diagnosis, multiple diagnosis, etc. 

<b>Request a copy of the health plan's/insurance company's Medical Policy.</b>  The Medical Policy is not your certificate of coverage, health insurance policy, or health care contract.  This is the set of policies used by the health plan/insurance company to make medical necessity decisions, and it deals with a wide variety of issues.  The Medical Policy (or criteria) determines whether a service or item is eligible for payment, or whether the service or item is experimental, investigative, ineligible. 

<b>Health plans/insurance companies typically exclude experimental or investigative procedures.</b>  FDA approval of a service/item does not guarantee coverage/payment by a health plan; in some instances, the service/item may not be clinically accepted, or the specific use of the service/item may be excluded for certain instances/applications. 

<b>If you have a special contact or a case manager, have them walk you through the rationale behind specific policies applicable to your treatment. </b>

<b>Experimental and Investigative treatments/services/items.</b> 
Technology is moving at an amazing pace.  Many accepted technologies and treatments are being used in new, innovative ways that may not have medical community acceptance, and new technologies are introduced every day.  Health plans/insurance companies may or may not pay for clinical trials related to experimental and investigative treatments/services/items.  Ask about clinical trials that the health plan may participate with. Work with your case manager to discuss options. 

<b>Benefit Deviations.</b> 
If you have coverage through your employer, benefit deviations may occur with approval from your employer.  Be aware that benefit deviations may pay for services that are not eligible for coverage, but there are direct IRS tax implications related to any such authorization of payment for ineligible services as a benefit deviation.  Payment of services through benefit deviation are reportable income, and will appear on a 1099 as such.  Most employers are reluctant to depart from benefits with a deviation because of the tax implications for the employee, and because any deviation sets precedent for future cases. 

<b>Benefit Substitutions</b> 
In the interest of extending health benefits, a health plan/insurance company may pay for a service/item/supply in place of another service/item/supply.  For instance, in lieu of an extended inpatient admission, home health services may be paid, if medically appropriate.  Usually done to conserve dollars, if a patient is reaching a life- time maximum, this is typically negotiated by a case manager. 

<b>Find out about your Appeal Rights</b> 
Appeal rights should be clearly provided to you in materials provided by the health plan/insurance company.  If you don't know what rights you have to appeal decisions, contact customer service and ask for a copy of your appeal rights.  Most health plans/insurance companies provide appeal rights in any written denial issued.  Most health plans/insurance companies will take your appeal either verbally, or in writing.  Due to confidentiality constraints, your health plan/insurance company will decline to handle such sensitive information via internet, but telephone, US Mail and facsimile transmission are acceptable methods of communicating. 

<b>Use regulatory oversight authorities to help you work through complaints or grievances.  Insurance is heavily regulated on a state and national level.  If you don't think you've been treated fairly, contact the Commissioner of Insurance, , the Department of Health, or the Attorney General in your state.  Each state regulates health insurance differently, but one of these three oversight authorities will take an interest in helping you resolve problems </b>

Grace and Peace, Strength and Courage, 
Lisa  2002
