In taking charge of your own healthcare needs, knowing your insurance benefits and communicating effectively will optimize your chances of having your medical care covered. You have the power to knowledgeably pursue all available avenues in obtaining coverage through your health plan benefits. The following easy tips will help you communicate effectively with your insurance company:
- Be confident when calling your insurance company. As
a valued customer, you have the right to obtain complete information
regarding your health benefits. Your insurance company's customer
service representatives are there to assist you. Part of their
job includes answering questions to your satisfaction.
- Communicate clearly and calmly. Remember that your
ultimate goal is to gain coverage for your healthcare and pulmonary
hypertension-related treatments. If you are met with resistance,
simply restate your request.
- If at first you don't succeed, try, try again. If
you have tried discussing your request with your health plan's
customer service representative but are not satisfied with how
your insurance matter was handled, ask to speak to:
- a supervisor in the Customer Service department
- the manager or director of Customer Service or Member Services
- Know your benefits. Health insurance can be complicated. Be sure you
know the benefits to which you are entitled under the provisions
of your policy. If you do not fully understand something, ask
your insurance representative or your employer's benefits administrator.
- Document all communication with your insurance company.
Be sure to keep detailed, written records of each conversation
you have with your insurance company representatives. Record
the date the conversation took place, the first and last names
of the representative with whom you spoke and make notes regarding
any information that was provided to you. Also remember to keep
copies of all written correspondence between you and your insurer.
- Follow up in writing after speaking with a health plan
representative on the phone. Keep your correspondence simple
and to the point. Include relevant dates, names of representatives
with whom you spoke and their message to you. Also be sure to
include your name, policy number and any other identifying information.
- Do not hesitate to request assistance from your employer's
Human Resources department and your physician(s). In many
cases, your employer makes decisions about what will and will
not be covered under your health plan. Your employer's support
can result in the approval of your request for coverage. In
addition, having your physician contact your health plan representative
can also be helpful since he/she can speak to the necessity
of the requested medical products or services for your overall
health.
- Carefully follow the steps outlined by your health plan
for requesting prior authorization, submitting claims or filing
appeals. Not following these steps may result in a processing
delay or denial of your request for coverage.
- Advocate at all levels. Write to your state health
insurance commission and/or your state and federal elected officials
and enlist their help by informing them of your health needs
and situation with your health plan insurance claim. Notify
your insurance company again that you have requested help from
the state health insurance commission and other agency representatives
in resolving difficulties in meeting your healthcare needs.
- Utilize the additional resources that are available. There
are a variety of organizations that can provide you with assistance
with insurance issues. These organizations may be specific to
your therapy (Tracleer Access Program or the Remodulin Therapy
Assistance Program) or specific to your disease state (PHA,
A.C.C.E.S.S.). Remember to enlist their assistance for additional
advocacy support.
- Be persistent! Remember that a denial is not necessarily
the final word. Ask your insurance company to reconsider their
decision and follow-up to make sure they are taking action.
Real Life-
"There are many different ways to approach the issue
of insurance and medical coverage. Having a chronic illness
and having to deal with insurance and financial issues is
one of the most emotionally draining aspects of PH. Be EXTREMELY
organized, keeping records of everything. Put it in chronological
order in a notebook - so many questions to answer, and you
need your information in front of you! Keep a listing of all
the contact numbers and make notes about your conversations
with the different agencies, noting person to whom you speak
(first and last names), extensions, times, and dates." |
Although following the items outlined in this guide cannot guarantee
that your health plan will cover your prescriptions and healthcare
services, (i.e., medical equipment, physician visits), understanding
your coverage and benefits will allow you to know that you have
done everything you can to get the most benefit from your health
insurance coverage.
This resource was developed in 2004. Some of the content may be out of date or no longer relevant. PHA is working to update and re-organize this guide. We apologize for any inconvenience.
