Question: How do I file a complaint if I am not satisfied with the services my child has received?
Answer: First, talk with your pediatrician about your concerns, no matter who provided the services. A partnership based on open and honest communication is very important to meeting your child's health care needs. This can often reduce the number of problems you may have in making your managed care plan work for your family. If you feel you need to file a complaint, call or write to the member service representative of your plan. See your plan handbook for information about filing a complaint. You also can contact your employee benefits manager for help.
Question: What options do I have when a claim is denied?
Answer: Managed care plans have specific procedures about denials of claims and appeals. Typically, your plan will let you know in writing if a service is denied. You may request a review of the denial by filing a written request with your plan, typically within 30 days after the denial notice. If you write an appeal letter, include additional reasons why the service was needed. A decision will be made about your appeal, usually within 30 to 90 days of the request. If you are still dissatisfied, you may want to contact the office of your state insurance commissioner to see if it can help. As a final step, you can take legal action. The best way to avoid problems is to know and understand your plan before you or your employer sign up with it.
This information should not be used as a substitute for the information found in your own health insurance plan contract
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