How to Fight with Your HMO

If your Health Maintenance Organization has refused to authorize medical care, sending you and your primary care physician a denial letter, fight the denial with an appeal letter and follow up with phone calls before you start exploring other payment options.

Things You'll Need

• Insurance card
• Explanation of benefits (EOB)
• Denial letter from HMO

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Instructions

• 1

  Understand your EOB.

  Read carefully through your EOB, which you can usually find online or in the documents you received when you enrolled in your HMO plan. Ask yourself whether the plan covers your condition under your specific circumstances. For example, a plan may cover loss of eyesight only when it is related to diabetes.

• 2

  Phone your insurance company.

  Once you have good reason to believe the HMO wrongfully denied your claim, call the 800 number on the back of your insurance card. Keep the card handy so that the company employees can verify your identity and insurance information. Explain that you will need to file an appeal for a denied claim, and ask for the appropriate paperwork.

• 3

  Write an appeal letter to state your case.

  Write an appeal letter. Explain why you believe you were wrongly denied coverage. Obtain medical records from your doctor, hospital or any specialists who have recommended that you be treated for your condition. Make reference to these documents in your letter and send them in with the letter. Fax your letter and documents to the insurance company for a speedier response.

• 4

  Remind your insurance company that you need a decision on your appeal.

  Make a phone call to follow up with the insurance company, confirming that it received your appeal documents. Appeals can take several days or several months. Ask when would be appropriate for you to call again to check on the status of your appeal. If you're awaiting a procedure that is fairly urgent, let the company know so it will come to a quicker decision. Ask your primary care physician or whoever initially referred you to follow up.

• 5

  Talk with your doctor about other avenues of payment.

  If the insurance company denies your appeal, set up an appointment with your doctor to explore other avenues of payment. For example, if you were denied eyesight coverage, check whether your employer offers a vision plan that you could add to your benefits. Ask your doctor whether a local charity offers low-cost vision services or whether you qualify for any government assistance. Your physician may have ideas or resources you don't know about.

• 6

  Find health care advice or case management help from an outside organization.

  If you and your doctor can't find a solution, seek outside help. Check out healthcareadvocates.com and patientadvocate.org, which can help you navigate complicated insurance issues. Request assistance with your specific issue, letting them know that neither your insurance company nor your doctor can find a solution to your medical issue.