Independent surveys of Minnesotans show most are satisfied with their health care plan. Each year, about three out of every 1,000 Minnesotans file a complaint against their health plan. Even though satisfaction is high and complaints are low, problems do occur. Minnesota health plan companies joined together to help you solve potential problems as easily and painlessly as possible.

One of the most important steps you can take is to read your health insurance plan's member handbook. The member handbook is your guide to your health insurance coverage. It will save you time and money to find out what is covered in advance of receiving health care services. If you have questions about what is covered by your policy, contact your health plan's member services department.

Coverage Issues
Networks/Drugs
Appeals
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Coverage Issues

What to Do If Your Health Plan Denies a Request for a Medical Procedure or Drug

Most medical care you need will be routinely approved for payment by your health plan. While it is rare for a health plan to deny payment, a request for payment may be denied because it is not a covered service, because an alternative treatment will be more effective for you or for other reasons. You can make sure your health plan makes the right decision about your medical care by being actively involved with your physician or other health care provider and by becoming familiar with your treatment options and your health plan's coverage and payment policies.

There are several reasons a health plan may not pay for certain medical procedures or drugs. If coverage is denied, your first step is to call your health plan representative to ask why. Their answer will help you decide what to do next.

Steps to Take If Your Health Plan Denies Coverage

Is the procedure covered by your health care policy?

Not all medical procedures are covered by health care plans. Since Minnesota health plans generally have very broad coverage, it is rare, but possible, that a procedure you need is not covered.

What you can do:

If you have questions about what is covered, talk to your employer or insurance representative, or call your health plan representative directly. If the procedure you want is not covered, you may have to pay for the procedure yourself or choose another treatment that is covered by your policy. Ask your health care provider to review the care options with you.

Is a referral or prior authorization required?

Today, most health plan companies will review some requests for procedures in advance, or require a referral from a primary care physician before they will pay for a procedure. This is because in the old-style health insurance system, medical claims were often paid without question. As a result, health care became unaffordable for most people since so much money was spent on ineffective, overly expensive and uncoordinated medical care. For example, routine medical services were too often provided by specialists at a much higher fee, or patients were admitted to the hospital for procedures that easily could be performed in an outpatient clinic.

What you can do:

Read your health insurance policy or member handbook to find out what steps you should take to obtain prior approval or a referral for a procedure you need. Your physician or health care provider can help you submit the request or obtain the referral. If you still have questions, call your health plan representative for help.

Does your health plan company have complete information about your request?

In addition to requiring prior authorization or referrals, health plans sometimes review certain requests to ensure the requested medical procedure is the most beneficial treatment or is performed by the right health care professional in the right setting. These decisions are made by a physician, nurse and other qualified health care professionals. Decisions are based on information provided by you and your personal physician or health care provider. Sometimes coverage is denied because the health plan needs additional information. The health plan may not know some facts that would explain why you need the procedure.

What you can do:

Ask your physician or health care provider to make sure all important information is given to the health plan. If your request is denied, ask your health plan whether its decision would be different if additional information was provided. If so, arrange to have the additional information provided to support your request for coverage.

Is an alternative procedure covered instead?

Sometimes coverage for a procedure is denied because a different procedure is more effective, less expensive or both. Health plans use medical guidelines developed by physicians and medical researchers to decide what works best. This approach allows health plans to lower your health care costs and improve quality by paying for medical care that has been proven safe and effective.

What you can do:

If a request for payment is denied by your health plan, ask your physician or health care provider about alternative treatments covered by your health care policy. Ask what the medical research studies and practice guidelines show works best. An alternative treatment may be more effective than the procedure you or your physician originally requested. On the other hand, your case may involve special circumstances justifying an exception to the general rule. Ask whether you may be eligible for an exception if you and your physician or health care provider can provide additional information demonstrating why your case is unique.

Networks/Drugs

Networks Provide Quality Care

Is your physician or health care provider in your health plan network?

Most health plans have a required or preferred list of physicians, hospitals and health care providers. These "provider networks" generally offer patients many different choices of health care providers, but not every health care provider is included. Health plans have found the best way to coordinate and manage medical care—and to get an affordable fee arrangement with health care providers—is to enter into a contract with a selected panel of qualified physicians, hospitals and health care providers.

What you can do:

Read your health insurance policy or member handbook to find out which health care providers are eligible to provide services to you. Many health plan policies allow you to use a provider outside of your provider network, sometimes by paying a higher copayment. If you do not have this kind of policy, you will need to choose from the providers in your health plan's network. If the regular provider network does not include a provider that is capable of providing a special kind of treatment you need, your health plan will make special arrangements for you to see a provider not normally included in the network. Work with your regular physician to locate a specialist or provider in your health plan's network who can provide the treatment you need. If necessary, discuss the procedure for going to a non-network provider.

Prescription Drugs

Is the drug you requested included in your health plan's formulary?

Old-style health insurance plans often paid expensive "retail" prices for prescription drugs since they did not question whether less-expensive alternative drugs were available. For example, payments were made for brand-name drugs when generic drugs were equally safe and effective, and less expensive. Most health plans today use drug formularies—a list of the prescription drugs the health plan covers. Health plans are obligated to meet your medical needs for drugs—if the formulary does not include a particular drug that will work for you, most health plans will authorize coverage of a drug not on the formulary.

What you can do:

Read your health insurance policy or member handbook to learn about your health plan's policies on coverage of prescription drugs. If you have asked for a drug not included in your health plan's formulary, it is likely that the formulary includes an alternative drug that will work for you. Talk to your physician or nurse about the options. If there are special reasons why none of the drugs in your health plan's formulary will work for you, you can ask your health plan to make an exception. Your physician or nurse can help you.

Appeals

After you have learned more about your health plan's reasons for denying payment, you may be satisfied with the decision, or you may have learned about an alternative procedure or drug that is covered. If not, you can file an appeal with your health plan company. An appeal is a process health plans use to review a patient's situation and determine whether the original decision to deny payment was the right one.

What you can do:

Read your health insurance policy or member handbook to find out how to appeal a decision. All Minnesota health plans allow patients to appeal, though the steps you must take to appeal may vary somewhat. If you need help, call your health plan's member services representative. Usually, you or your physician will need to send a letter to your health plan explaining why the treatment is necessary and why it should be covered, and requesting reconsideration of the original decision. You may also want to send a copy to your employer if your health plan is purchased through work. Always keep a copy of the letter in your own file. Also keep track of your conversations with your health plan representative—write down dates, names and notes summarizing what was talked about. Your health plan is required to respond promptly to your appeal. It will notify you of its decision. You may have the right to a second appeal if you still are not satisfied.

• Most complaints and appeals are resolved internally by health plans to the member's satisfaction. Some are not. If you are not satisfied, there are other places to go for help.

• If your health plan is a Minnesota-licensed HMO, you can appeal to the Minnesota Department of Health, the state agency that regulates HMOs. If your health plan is a Minnesota-licensed health insurance company, you can appeal to the Minnesota Department of Commerce, the agency that regulates health insurance companies. If you have a Minnesota-licensed health plan, the telephone number to call for state help is listed on the back of your membership card and in your member handbook.

• Many employer-sponsored health plans are not regulated by the state of Minnesota. If you have this kind of plan, you will not have the phone number of a Minnesota state agency on your membership card or in your handbook. Call the member services number that is listed instead, or contact your employer directly.

• If you are enrolled in MinnesotaCare, Medical Assistance or General Assistance Medical Care, you are eligible for special assistance and a special appeals process. Call Customer Services Recipient Help Desk at (800) 657-3739 for more information.

• Court action is also an option.

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Resources Outside Your Health Plan

For information comparing health plans, contact the Minnesota Information Clearinghouse at (800) 657-3793.

If you have questions about health care coverage, Medical Assistance, General Assistance Medical Care or MinnesotaCare, call the Customer Services Recipient Help Desk at (800) 657-3739.

Filing An Appeal

If your health plan is a Minnesota-licensed HMO, you can appeal to the Minnesota Department of Health at (651) 201-5100 or (800) 657-3916.

If your health plan is a Minnesota-licensed insurance company, you can appeal to the Minnesota Department of Commerce at (800) 657-3602. (You can tell what kind of plan you have by looking on the back of your insurance card; the name of the appropriate state or federal agency should be noted.)

Employer-Sponsored Health Plans

Many employer-sponsored health plans are not regulated by the State of Minnesota. If you have this kind of plan, you will not have the number of a state agency on your insurance card. If you have questions about your coverage, your first step is to call your health plan's customer service number or your human resources contact.

If you need assistance from a government agency, you can contact the U.S. Department of Labor at (816) 426-5131.

For Seniors...

If you have questions about Medicare, call the Minnesota Health Insurance Counseling Program (run by the Minnesota Board on Aging), (800) 882-6262.

If you need information on community services available to you, call the Minnesota Health Insurance Counseling Program - Senior Linkage Line (800)333-2433.

If you have questions about Medicare managed care insurance policies, call the Senior Linkage Line noted above, or call the Minnesota Department of Health managed care division at (651) 282-5600.

If you have questions about Medicare Commercial Supplement insurance policies, call the Minnesota Department of Commerce at (800) 657-3602.