Your Rights And Responsibilities

Some tips to help caregivers make the most of a managed health care insurance plan.

Many states have instituted a bill of rights for managed care consumers. This series of protections varies, but some of the more common, and most important protections, include:

  • All Managed Care Consumers have the right to appeal any denial of health services.
  • A letter explaining any denial and the appeals process is required.
  • You have the right to collect all relevant information from medical providers.
  • The plan is required to consider all such appeals and respond in a timely fashion
  • If you require a quicker review, you have the right to request an expedited review and the plan is required to respond within a shorter period.

10 Managed Care Tips for Caregivers

  1. It’s worth the time and effort to read and understand the documents provided by your loved one’s insurance company. This includes evidence of coverage, as well as other documents such as member handbooks, provider directories, newsletters, and other material.
  2. Know as much as you can about the plan before your loved one uses it. It’s particularly important to know the primary care provider, the plan’s policy regarding referrals to specialists, co-payment requirements, and access to emergency care. Be prepared. The plan will probably not cover all of your loved one’s medical expenses, and he or she may have to pay part of the cost.
  3. Ask questions about anything that isn’t clear.
  4. If you need assistance, contact the plan’s representatives, your loved one’s insurance agent, his or her employer, or the office of the managed care ombudsman.
  5. If a problem arises, you should first contact your loved one’s managed care plan. The evidence of coverage contains a telephone number and mailing address. Be sure to record the day you call, the name of the person you speak with, the title of the person you speak with, and a summary of the conversation.
  6. If your loved one or his or her physician has difficulty obtaining approval for medical care—or experiences difficulty with a claim—know what your loved one’s rights are according his or her particular plan.
  7. Follow the instructions provided by the plan to appeal an adverse decision. Familiarize yourself with the levels of appeals and grievance procedures that are available through the plan’s internal process.
  8. Carefully document—in writing—the facts that support your case. Keep your letters business-like and clearly state why you believe you are correct. Include copies of documents from your loved one’s physician that support the appeal.
  9. Follow the time lines and meet the deadlines set up by the plan. Be sure to keep a copy of any letters you send.
  10.  At any point in the process, feel free to contact the office of the managed care ombudsman for assistance.

The tips above were supplied by The Office of The Managed Care Ombudsman, the Bureau of Insurance, Commonwealth of Virginia. Check with the appropriate office in your loved one’s state for information regarding specific regulations.

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