How to Solve HMO Grievances:

As the parent of a child with an HMO policy, you may have to file an HMO grievance. It is essential to understand this process ahead of time to ensure that you will be prepared and informed of your rights. Even if you never have to file an HMO grievance, the following steps can help you learn more about your child's health coverage and the insurance company's practices.

A grievance can vary from denied medical care to an administrative or billing error. However, the procedures for handling different types of grievances are usually the same.

1. Get copies of your child's insurance policy. Your insurance company should provide you with documentation for your child's policy. This documentation should include the policy itself, information on what is and is not covered, as well as the steps you will need to take if you do need to file a grievance.

2. Read the procedure. Each insurance company may have a different procedure for filing a grievance. It is important to understand this procedure ahead of time, and to make sure that you are filing the grievance within the allotted time. You may be limited as to when you can file your grievance, such as up to one year after the initial grievance occurred.

3. Keep all contact information on hand. Your insurance company's grievance procedure should include a list of contact numbers, employees in charge of handling grievances and additional information. Keep this information in a location that is easy to access so that you will have everything ready should you need to file a grievance.

4. Thoroughly document the grievance. You will need to be able to back up your grievance claim by providing documentation of your position. For example, if your policy states that coverage for a specific area will be provided and they later refuse coverage, you would need a copy of the original policy as well as the refusal.

5. Begin the process. Once you have all of your information ready, you can begin the grievance process. You will normally be required to call a toll-free number to report the offense to the insurance company. This will get the ball rolling.

6. At this point, your insurance company may require binding arbitration. This means that both sides will be able to present their case to a third party arbitrator. The arbitrator's decision will be binding, which means that you will not have much further recourse. Your steps to document your grievance will come in handy if it does go to an arbitration. Once the decision of the arbitrator is made, the grievance will be considered handled.

7. If the insurance company does not use binding arbitration, they may issue their own opinion on the grievance. If they do not respond if your favor, you may be allowed to appeal their decision. Each company may have a different protocol for handling appeals, but generally, your state's department of children and families or DCF, will be provided with a copy of the grievance as well as their decision. This department will then advise you on your further rights and the appeal process.

Most grievances are resolved within 30 days, but must be resolved within 60 days. In the event that more information is required, you or your insurance company may request a 30 day extension.

If you need to expedite the review process of your grievance, your HMO should provide you with the necessary information on how to undertake this step. This can help move the process along much faster, particularly if the grievance deals with a medical issue instead of an administrative issue.

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