OHA: Step 1

Three Step Complaint Process

Step One

Talk to Your Doctor

If you have a concern about a service that was not covered, ask the doctor's office exactly why your health plan is denying the service. Find out what information was submitted to the plan and ask for a copy of the information and the letter written by your doctor to the plan requesting payment authorization.

Call Your Health Plan

Many problems and concerns are resolved at your health plan's customer service department (also called "member services"). You can find the toll-free number to contact them on your membership card.

The health plan has an obligation to help you resolve your problems. Be sure to ask for and write down the name of the person assisting you so that you can speak with him or her again if you need to call back.

When you call your health plan, your complaint will probably be recorded, either by entering your information on a computer or by taping it as part of the health plan's monitoring of customer service. You should be told if a tape recording is being made. This is one way that health plans can measure the satisfaction of their members, but it also means that whatever you say could become part of your record.

Call Your Employer

If you get your health coverage through your own or your spouse's job, the human resources or benefits manager may be able to help resolve any questions about benefits and health plan policies. If you received an employee handbook, check it to see if there is a procedure to follow regarding questions or problems with your health benefits.

Now that you have talked to all parties involved, doctor, health plan, and employer, you should have a good understanding of what went wrong. If you are not satisfied with the resolution of your problem at this point, you can file a formal grievance. You will probably need to submit your description of the problem in writing. Step Two will go into more detail about filing a formal grievance or complaint.