How To Settle a Dispute with Your HMO

By Cecilia Green

Published on August 12, 2005

When an HMO rejects a medical claim, many individuals are reluctant to contact their HMO, dreading the hassle of trying to get their claim approved. To assist individuals in resolving these disputes, a step-by-step guide has been published by the Kaiser Family Foundation and Consumers Union.

According to the guide, the first step you should take as an HMO subscriber is to know your health plan. You should be aware of all the services that are covered in your plan and the services that are not. This way, when you are sick or injured and need immediate treatment, there is no confusion as to what your insurance policy will cover.

If it turns out that your insurance provider is denying coverage for necessary treatment that should be covered under your policy, it is important that you document your case. This includes collecting bills, test results, and benefit statements that may help with your claim.

If you fail in negotiating with your insurance company, you may need help from an outside source. Depending on the insurance coverage you have, there may be a review process to settle disputes provided by your particular insurance company, such as Medicare or Medicaid. Other options include resolving the dispute through the Department of Labor, filing for an external review within your state, or filing a lawsuit.

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