How to File an HMO Grievance with your Child's Health Insurance
As the parent of a child with health insurance through an HMO policy, you may one day need to file an HMO grievance. If this situation occurs, it is essential to understand this process ahead of time to ensure you will be prepared for the process. It is also important that you understand your rights.
Even if you never have the need to file an HMO grievance, the following steps will help you learn more about your child's health coverage and the insurance company's practices, and prepare you for future unforeseen grievances.
When to File an HMO Grievance
HMO grievances can occur for many reasons. A grievance can range from denied medical care to an administrative or billing error. However, the procedures for handling different types of grievances are usually the same.
How to File an HMO Grievance
1. Get copies of your child's insurance policy.
Your insurance company should provide you with the appropriate documentation for your child's policy. It should not only include the policy itself, but information on what is and is not covered, as well as the steps needed to file a grievance.
2. Read the procedure.
Every insurance company has different procedures for filing a grievance. It is important to understand your company’s particular procedure ahead of time, and make sure you are filing the grievance within the allotted time. You may find that you must fill out the same information several ways, or are required to use a special form. Failure to follow the health insurance company’s procedure will significantly delay your claim.
3. Keep all contact information readily available.
When filing a grievance, you are likely to send several forms, write a few emails, and make many telephone calls to get your claim filed. Keeping important contact information handy will help reduce your frustration during this process. Your insurance company's grievance procedure should include a list of contact numbers, employees in charge of handling grievances and any additional, pertinent information. Keep all information in a location that is easy to access so you will have everything accessible should you need to file a grievance.
4. Thoroughly document each step of the grievance.
You must be able to back up your claim by providing ample documentation of your position. If your policy states coverage for a specific area will be provided and your company later refuses coverage, you will need a copy of the original policy in addition to the refusal. When filing a grievance, having the right information well documented can help streamline the claim. In addition, if you are knowledgeable bout the details of the claim, it is easier for the insurance company to process your claim speedily. Also, in the event that your grievance progresses to a lawsuit, you will need thorough documentation to make your claim.
5. Start the process.
With your detailed 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 and get the ball rolling. Be sure to gather all forms and information before calling to save time.
6. Your insurance company may require binding arbitration.
This means both sides will be able to present their case to a third party arbitrator. The arbitrator's decision will be binding. In the event that third party arbitration is utilized in your case, you will not have further recourse once a decision is made. Your steps to document your grievance will come in handy if your claim goes to arbitration.
7. Look into arbitration and appeal if necessary.
If the insurance company does not use binding arbitration, they may issue their own opinion on the grievance claim. If your insurance company does not respond in your favor, you might be permitted to appeal the decision. Each company has 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 in addition to the decision. This department will then advise you on your further rights and the appeal process.
More About HMO Grievances
Most grievances are resolved within 30 days, but must be resolved within 60 days of the initial filling of the grievance claim. 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 be able to provide you with the necessary information on the best method for embarking on this step. This can help move the process along much faster, particularly if the grievance deals with a medical issue instead of an administrative one.