How do I make claims under a self-insured health plan?

Making claims is a very important step for many consumers. If you are under a self-insured health plan, there are certain things that you must be aware of in order to correctly make a claim.

Taking the right steps when filing a claim has never been easier thanks to the great advice provided by the DOL. These steps must be followed when you have a health plan that’s under ERISA jurisdiction. Follow these rules before filing a grievance or appeal a benefit denial:

• Your summary plan description (SPD) should be read and thoroughly comprehended by you: Your rights and protection under ERISA – the federal Employee Retirement Income Security Act – should be listed under this plan description. Ask your plan administrator for an SPD if you don’t have one already.

• Your plan’s rules for filing a claim must be followed: In order to get what you want or to do what you want, you must first follow the rules that are given to you by your insurance company. This will prevent any misunderstandings that might later haunt you in the future.

• Understand the requirement of your plan: This goes along with the advice before this one. Every plan has various requirements that should be followed.

• Waiting period rights should be known: After filing a claim,   your health plan must tell you whether you will receive benefits or if additional time is needed to consider the request within 90 days. If more than 90 days is needed, your health plan should have a pretty good reason to explain why.

• If your claim is denied, know what your rights are: Your health plan is required to tell you why your claim was denied. You should also be informed about how to appeal for a denial by your plan administrator.

• Know what your rights are under the appeal process: If you are going to make that appeal, then it is highly recommended knowing what your rights under the process that you are going to take. Knowing this is important. Contact your insurance agent so he will further notice you about the appeal process.

If, for some reason, you don’t understand something or you simply need more information, don’t hesitate to contact your insurance agent. This will help you better comprehend what you are going to need and what your limits are. Follow your plan’s rules and follow the advice listed above for the best and easiest claims process.