OHA: Determine the Problem

Coverage Problems

Determine the Problem

Problems can come up for many different reasons. The coordination of health care benefits can be complicated--it involves the doctor or the doctor's office, the patient, the health plan and sometimes the employer. The more familiar you are with the health care system and how it works, the more effective you can be in resolving your problem or issue.

Some of the problems that may come up:

  • Difficulty in getting specialty care
  • Limitations on services or benefits
  • Denial of a claim for health care services received because it is not considered a covered benefit, or the care is received outside the participating network of providers and facilities
  • Not satisfied with the quality of service you received from the doctor(s), other health care professionals, or the facility
  • The length of time it takes to get a doctor appointment
  • The time it takes to get the treatment or procedure authorized
  • If you have received a denial letter from your managed care plan, it should include a specific reason for the denial and a reference to your health plan explaining the basis for the denial.

Check your contract

If you believe that you have been denied a covered benefit, service, or timely access, look in the Plan Design Summary you received when you signed up with your health plan. If you write a complaint, state the specific benefit the same way as it is written in your policy document. If you can't find your policy document, ask your health plan's customer service department to send you one. Check to make sure that you have been denied something that is covered in your health benefit plan.