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Filing Health Insurance Claims

Before you file a claim read your benefit booklet and understand what is and is not covered. Follow all procedures and deadlines for seeking treatment and filing complaints and appeals. Most insurance companies maintain a toll-free telephone information and complaint line, and some companies and HMOs provide special mediation or arbitration procedures for handling complaints.

Here are a few tips for handling claim or reimbursement problems:

  • For group coverage, contact your group health benefit plan benefits administrator, if one is available. If there is no benefits administrator or if you have an individual health care policy, you should contact the insurance company or HMO.
  • Submit a written complaint to your health benefit plan, insurance company or HMO specifying your concerns.
  • Ask for explanations in writing and keep good records, including the names of people that you talk to while trying to resolve the matter.
  • If you do not resolve the matter, file a formal complaint with the Office of the Commissioner of Insurance (OCI).
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