What You Need to Know About Your Health Insurance

Tips for Effectively Managing Your Health Insurance

  1. Check your policy to be sure any treatment you're seeking is covered.
  2. If you aren't sure about anything in your policy, call your insurance company's customer service number and ask questions. Write down the date, time and name of the person you speak with.
  3. When you send documents to your insurance company, either fax them and keep the fax conformation or send them certified mail. Always keep copies of anything you send.
  4. Usually, your doctor must call to pre-certify medical procedures. However, you should also call the insurance company to get the pre-certification number. Keep this number for your records.
  5. Pre-certification does not guarantee payment.
    • Ask your insurer if there's any reason your pre-certified procedure will not be covered.
  6. If you're facing surgery, be sure all medical providers involved are covered in your plan's network.
    • Many plans won't pay for providers like certified registered nurse anesthetists (CRNAs) or physician assistants (PAs)
    • Also, using an in-network facility with an in-network surgeon DOESN'T GUARANTEE everyone involved in your care (anesthesiologist, radiologist, etc.) is in your plan network.
  7. If your doctor refers you to another doctor or recommends a medical procedure/ diagnostic service, be sure your plan covers the recommended procedure and provider.
  8. If you're in an HMO or PPO plan, treatment may need to be coordinated through your primary care physician (PCP).

Filing Claims

  1. Check the time limits for filing a claim.
  2. Find out if your medical provider submits the claim or if you need to submit it.
  3. If your medical provider submits the claim, find out if you need to supply claim form. Be sure the provider's office has your up-to-date insurance information.
  4. If you need to submit the claim, review the information to be sure it's complete and correct.
  5. File the claim as soon as you get the bill.
  6. Be sure to send your claim to the address listed on your insurance card.
  7. Keep a copy of the filed claim for your reference.

Questions to Ask When Shopping for Health Insurance

  1. Is your doctor in the plan's network?
  2. Will the plan pay for preventive care, prescriptions, immunization, well-baby care, mental health, health services, chiropractic care, physical therapy, speech therapy, etc.?
  3. What does the plan exclude?
  4. What are the limits on pre-existing medical conditions?
  5. How much do you have to pay when you receive health care services (co-payments, deductibles, and co-insurance)?
  6. Are there separate deductibles for hospital care and general medicine care for in-network and out-of-network services?
  7. Are there limits on how much you must pay for health care services you receive (out-of-pocket maximums)?
  8. Are there limits on the number of times you may receive a service (number of visits, lifetime maximums, or annual caps)?
  9. How often can rates be changed?
  10. Do rates increase as you age?
  11. Has the company had an unusually high number of consumer complaints? (Check with your agent or the Department of Insurance.)
  12. What is the average turnaround time on claim payment?
  13. Is there a Consumer Choice Option and how much does it cost.


When Buying an Insurance Policy....

  • Read and understand your insurance policy before buying
  • Get everything in writng. If you pay for a policy, get the policy. If you sign anything, get a copy. If an agent shows you a comparison of rates or other documents, get a copy.
  • Pay your premium at the same time every month, even if you haven't yet received your bill. If you don't pay on time, your insurance carrier can cancel your policy for non-payment

If Your Claim is Denied

  • The reason for the denial should be stated on your Explanation Of Benefits (EOB)
  • If you don't agree with the reason for denial check your policy or employee booklet for the insurer's appeal procedures.
  • Know the time limit for filing an appeal.
  • Your appeal should be in writing. You may need information from your doctor.
  • If you've used all the appeals available through your insurer, you may be eligible for an Independent Review.
  • Be Persistent!


Being informed and documenting any interactions with your insurance company is critical to protecting yourself as an insurance consumer !

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