What Do You Mean It's Not Covered?

Spring 2002 CARES Foundation, Inc.

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What Do You Mean It’s Not Covered?

As many of our families can tell you, the challenge of getting medical coverage for a chronic disease, such as CAH is often frustrating and extremely stressful. Tricia and Calvin Luker, from Michigan, who are parents of a child with a metabolic disorder, have written two excellent articles on how families can best approach these financial concerns. Below highlights some of the important points that they raise.

To get the most out of your insurance company you need to develop a thorough understanding about your policy. If you have frequent claims, you should consider the following:

Withhold payment of the medical bill until you receive insurance payments if you are on a tight budget. Discuss your financial situation with your doctor. Generally, you only have to make a small payment every month to ward off bill collectors.

Work directly with one particular claims examiner. When they get to know you and your family’s medical situation, often they are better able to assist you. Make sure you keep notes on who you spoke with and when.

Submit claim forms carefully and methodically. Have a separate "Claims Submitted" folder for each member of the family with copies of all claims, bills and correspondence. Your copy is important protection in the event the paperwork is lost or replaced or needed for future reference. Also, include a reference list of prescription numbers with the names of the drugs in your folder.

Check your claim carefully before submitting to ensure that it is not delayed because of incomplete information; don’t claim too many different types of items on one form. If one is rejected, it may delay the processing of the entire claim.

If you were denied coverage and believe that you are entitled to payment under your plan, these are some steps that you can take:

Appeal your denied claim to your health insurance company at least twice.

If you are not reimbursed after these appeals without adequate explanation, contact your state’s Department of Insurance and ask to speak with someone in the Office of Consumer Affairs regarding a health insurance problem.

Send the person you speak with a written description of the problem and any literature from your insurance company that supports your case that the service should be covered, and any additional information you feel is important. Give the Department of Insurance two weeks to respond. If you receive no response, call them again and speak to the person you originally contacted. Wait another two weeks. If you still get no satisfactory response and the amount is sizable, consider talking with an a lawyer to resolve your case.

The Lukers’ articles also include explanations on how to seek out other financial sources if your medical insurance is not sufficient to meet your needs and professionals who can assist you in this search. Some of the financial sources they suggest include: tax-supported government programs at the local, state and national levels; voluntary health agencies; and charitable organizations.

To read the original "What Do You Mean It’s Not Covered?" articles in their entirety, logon to the CARES Foundation website at: www.caresfoundation.org.

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