LARGE TEXT BOX Tool to enlarge text.


Select a button to change the background color on this page.



Strategies for Dealing with
Health Insurance Companies and HMOs


Guiding principles for dealing with insurance companies:

What to do when you're told the service or equipment isn't covered

Determine what is covered:

If there's a reasonable argument under the master policy that the service or equipment should be covered, file an appeal (see below)

If not covered under the master policy try to make a deal

Medical necessity determinations

What's needed in a letter of medical necessity:

Working with the prescriber Where the plan offers a less expensive alternative Whether the providers who are in the plan's network or will accept the reimbursement offered by the plan are accessible and competent

Lack of providers with physically accessible offices (For HMOs and PPOs)

Lack of competent specialists Filing appeals/grievances with HMOs and "gatekeeper" PPOs (Preferred Provider Organizations)

Complaints vs. Grievances

Levels of Grievances 1st Level Grievance

Subscriber rights

Time limits Grievance Committee Date/notice of hearing Right to appear/ be represented Right to question staff Disputes involving differing physician opinions Hearing process Hearing decision 3rd Level Appeal- Dept. of Health

Time limits

How to appeal Departmental hearing Expedited grievances for "medically pressing issues" Persons on Medical Assistance in HMOs What to do for more help
drafted by David Gates10-14-97

Prepared by the Pennsylvania Health Law Project

Return to Legislative Update