Are you having a problem with your health insurance? Well, even though there are a number of things you can do, you need to know what kind of coverage you have in order to get the help you need.

Karen Stiles of the TODAY’S TMJ4 Call 4 Action office has more information on how to get help with your medical claims.

The type of health insurance that you have affects how and where you can go for help. Many of us have coverage through work, and as a result, we might just assume that we have a traditional group health plan, which is regulated by the commissioner of insurance. However, what we may not know is that our plan might actually be a self insured health plan, which is not regulated by the commissioners office. Now, although all plans offer some type of right to appeal, you may find that you will have to go a different direction if your plan is self insured. If this is the case, you will need to pursue your claim under the ERISA Act with the U.S. Department of labor.

If you have a problem with a health claim being denied, first, read your plan thoroughly and follow all of the rules for getting the claim paid at the maximum level. Make sure that you get referrals, pre-approvals, and verify whether or not the provider is in network.

If you disagree with a denied claim, ask the insurer or plan administrator how to file an appeal and do so in a timely manner with as much supporting documentation as possible.

If you have exhausted all of your appeal rights, and you have a traditional group health plan, you can contact the commissioner of insurance for information about filing for an independent review. However, if your plan is self insured, you are going to need contact your human resources department or the U.S. Department of Labor and ask how to pursue the claim under ERISA.

Although you many never notice a difference, especially if the claim gets paid under appeal, you may find that you have less options if your plan is self insured verses a traditional health insurance plan.

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