What To Do If You Have a Problem

Getting the best care and service requires that you follow certain routine procedures with your providers and that you keep good records. Also...

• understand how your health insurance works,
• know what your rights are, and
• know how to file a legitimate complaint.

Most plans have procedures for handling disagreements or grievances about your health care or payment disputes. The following checklist should help you know what information you will need and how to proceed.

Information To Obtain And Keep

• Make and keep copies of all correspondence including bills and claim forms.
• Document conversations and include the date, the name of the person with whom you spoke, and the details of the conversation.
• Get copies of test results as well as any medical information about yourself from your provider. (There may be a charge for obtaining copies of these documents.)

How And Where To Get Help

• Make your complaint known to your group plan administrator, employer, agent/broker and/or customer service representative.
• Ask for a second review of your complaint if you are not satisfied with the result.

If you are still dissatisfied, you can bring your concerns to the attention of

• your employer's benefits or human resources department,
• the State Corporation Commission's Bureau of Insurance,
• the Virginia Department of Health's Center for Quality Health Care Services and Consumer Protection, or you may
• seek satisfaction through the legal system.

When You Ask For Help

Make sure you give the reviewers all the information they will need to investigate your complaint. Here's a checklist to help you organize the information that may be needed.

About You...

• Your name
• A phone number where you can be reached from 8:30 a.m. to 5:00 p.m. on weekdays
• Your home mailing address with city, state, and ZIP code
• The name of the patient who was seen
• The name of the insured
• Your policy, certificate, or individual or group identification number

And About Your Problem

• The nature or description of the problem or complaint
• The date of the service
• The provider's name who rendered the care (physician, facility, etc.)
• The original insurance claim number

And Remember...keep copies of all correspondence,invoices, and other papers related to the complaint.