The information in this section covers basic facts about how health insurance plans work but is not intended to provide specific details about individual benefit programs.

For answers that will be specific to your own individual health coverage, please contact your Human Resource Department, your Plan Administrator, the member service line of your Insurance Plan, or the broker responsible for your Insurance Plan.

In addition, you may want to click on to the Health Insurance Glossary for definitions of common health insurance terms.

• Why did my Plan/Service reject my claim? Why wasn't more paid on my claim?

• Why wasn't there more paid on my claim?

• Why do I have to pay for services if they are done in the network and/or with participating doctors?

• Where do I send my claims if I am required to submit my own?

• What phone number should I call for information about my health insurance plan?

Why did my Plan/Service reject my claim? Why wasn't more paid on my claim?

Claims questions are very specific to each person and to each health insurance plan, so there are many different reasons for denials, partial payments, or rejections of claims.

It is very important to understand the kind of health insurance coverage that you have because insurance companies can offer many different kinds of coverage under many different kinds of plans. So, even if you and someone else you know deal with the same insurance company, the kinds of health care benefits that each of you can receive might be very different.

The health insurance glossary tab on the home page of this site describes some of the different types of plans like HMO's, PPO's and so forth.

1. Start by answering the following questions and/or checking your Member Handbook:
   1. Were the services you received covered under your particular plan?
   2. Was the person who received the medical services eligible to receive them?
   3. Did you get a referral, if one was needed, before you went for treatment?
   4. Are you required to pay if you seek medical care without getting a referral, even if a provider is in the network associated with your Insurance Plan?
   5. Are there other procedures you must follow before you seek treatment? Pre-certification, etc.
   6. Are you responsible for a certain amount or a percentage of the cost for any or all treatment?
   7. Is the claim subject to partial payment according to the type of insurance plan you have?
   8. Did you receive services that had a limitation of benefits under your particular plan?
   9. Was the medical treatment related to an automobile accident or workman's comp injury?
   10. Was the treatment considered medically necessary?
   11. Was the service considered an elective treatment?

2. Did the doctor, hospital or other provider billed correctly for their services? Before you call the insurance company, the doctor, hospital or other provider, get out the explanation of benefits (EOB) that you received from the insurance company telling why they did not pay. It can be confusing at first, but most of these forms have numerical or alphabetical codes that give reasons for the denial of payments for medical services.

3. Did you provide current and accurate insurance information at the time you received the medical service? Has your insurance changed since your last doctor's visit? Are you under someone else's coverage at this time? Have you moved and not told the receptionist who filled out your form? Was this a work-related injury?

4. Did the insurance plan make a mistake when they entered the information into their computer system? There is helpful information on the receipt that you got from the hospital or doctor's office, so keep this slip handy when you call the insurance company to see if they made a keying error.

Why wasn't there more paid on my claim?

Claims questions are very specific to each person and to each health insurance plan, so there can be different reasons for denials, partial payments, or rejections of claims.

It is very important to understand the kind of health insurance coverage that you have because one insurance company can offer many different kinds of coverage under many different kinds of plans. So, even if you and someone else you know deal with the same insurance company, the kinds of health care benefits that each of you can receive might be very different.

The health insurance glossary tab on the home page of this site describes some of the different types of plans like HMO's, PPO's and so forth.

1. Review these questions or check in your Member Handbook for additional information:
   1. Were the services you received covered under your particular plan?
   2. Was the person who received the medical services eligible to receive them?
   3. Did you get a referral, if one was needed, before you went for treatment?
   4. Are you required to pay if you seek medical care without getting a referral, even if a provider is in the network associated with your Insurance Plan?
   5. Does your insurer require you to follow other procedures before or after you go for treatment?
   6. Are you responsible for a certain amount or a percentage of the cost for any or all treatment?
   7. Is the claim is subject to partial payment according to the type of insurance plan you have?
   8. Did you receive services that may have had a limitation of benefits under your particular plan?
   9. Was the medical treatment related to an automobile accident or workman's comp injury?
   10. Was the treatment considered medically necessary?
   11. Was the service considered an elective treatment?

2. Did the doctor, hospital or other provider billed correctly for their services. Before you call the insurance company, the doctor, hospital or other provider, get out the explanation of benefits that you received from the insurance company telling why they did not pay. It can be confusing at first, but most of these forms have numerical or alphabetical codes that give reasons for the denial of full or payments for medical services.

3. Did you provide current and accurate insurance information at the time of service?

4. Did the insurance plan make a mistake when they entered the information into their computer system? There is helpful information on the receipt that you got from the hospital or doctor's office, so keep this slip handy when you call the insurance company to see if they made a keying error.

Why do I have to pay for services if they are done in the network and/or with participating doctors?

It is very important to understand the kind of health insurance coverage that you have because one insurance company can offer many different kinds of coverage under many different kinds of plans.

1. Check your Member Handbook first to verify the kind of coverage in your particular Plan.
   1. Are you responsible for a certain amount or a percentage of the cost for any or all treatment?
   2. Were the services you received fully covered under your particular plan?
   3. Did you get a referral or follow all other procedures required by your insurer?
   4. Are you required to pay if you seek medical care on your own, without a referral, even if a provider is in the network associated with your Plan? Coverage under a Point of Service Plan is an example. You can go to a provider who is not in the network, but you will pay higher out of pocket expenses.
   5. Did you receive services that may have had a limitation of benefits in your particular plan?
   6. Was the treatment considered medically necessary?

Where do I send my claims if I am required to submit my own?

The address you must use to submit your claims is specific to your Plan. Submitting a claim to the wrong address can significantly delay payment or cause bills to be sent to you.

This address can be found in your Member Handbook, on your Identification Card, or on the Web site for your Plan. In addition, your employer or Plan's Member Services can give you this address.

What phone number should I call for information about my health insurance plan?

Phone numbers are specific to your individual health plan.

These phone numbers can be found in your Member Handbook, on your Identification Card, or on the Web site for your Plan. Many Plans have toll free numbers for your convenience.

Your employer or the Member Services Department of your insurance plan can answer this for you if you are unable to locate the phone number.

* If you still have questions, your employer or the Member Services Department of your Plan can help you find the answer.