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Resolving problems with your health plan

Call your health plan to see if you can resolve the problem

Problems are often resolved by simply taking time to talk and listen. Here are some basic tips for trying to resolve the issue yourself by calling your health plan. If you are not able to solve your problem by talking to your health plan, you can file a grievance, appeal or request a state fair hearing. If you need more information, call a state ombudsman for help.

  • Be informed. Read the Evidence of Coverage and any notices you get from your health plan. Keep these in case you need them later. The Evidence of Coverage describes the types of services you may be able to get and any special conditions for coverage, such as authorizations needed.
  • Be prepared. Have all the information you need when you make any phone calls. For example, your health plan ID card, notices that you received from your health plan and information about the medical services that you are asking for.
  • Be pleasant. Getting angry or rude will not solve the problem and may confuse the real issue.
  • Be clear. Explain what you want and why.
  • Keep records. Take notes: write down the date and time, the name and title of each person you talk to and a summary of what you talked about. You may need this information later if you decide to file a grievance or appeal, or request a state fair hearing.
  • Ask questions. Ask why the health plan or program did what they did. Ask for rules, policies or laws used to make the decision.
  • Be persistent. If you have asked your health plan to review a decision, ask when you can expect to get an answer. If you do not get an answer by that date, call back.
  • Read everything sent to you. Many decisions may be appealed but have deadlines and procedures you need to follow. Notices should always have information about how to file an appeal.
  • Important! If you get a bill, DO NOT throw it away.
    Call the provider to find out what the bill is for. Call your health plan to find out why they have not paid the bill.
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