While presenting to groups of newly insured persons, it became clear that many were at a loss as to how they should be using their new insurance card and how to react if they were not getting the benefits promised. The Appeals/Complaint processes for most insurance companies can be very confusing and often take a long time, but we must use them if we are ever to improve health care delivery.
Customers can find these processes in their policies or on their insurer’s website – some begin with a toll-free number, others may have a form. Timelines for responses by the insurer must be given and the next steps for customers who are not satisfied must also be given.
If the issue is a provider issue, always start by talking with that provider to see if the issues can be easily addressed and solved.
It is EXTREMELY IMPORTANT that you have good documentation of your appeal/complaint:
a short description of the nature of your concern; dates; times, who you talked with about the issues, their response, etc. Keep this documentation and add to it if more appeals/complaints are necessary at the state Insurance Commissioner level.
Some issues that are reasons for using appeal/complaints processes are:
- A claim is denied by your insurance company that you believe should be covered;
- If a provider listed on the insurance company’s list of providers is not accepting your card;
- If a service is not meeting your need, such as an office is too far or transportation benefit for Healthy Michigan is unreliable or you can’t get appointments within two weeks, ;
- The number of visits allowed by your policy are not sufficient for your mental health, substance abuse, or rehabilitative needs, according to your provider;
- A prescription drug is moved to a different, more expensive formula and you can no longer afford it.
If you need help with an appeal or complaint, call the toll free number for the Ombudsman at the Michigan Insurance Commissioner’s Office: