My health insurance claim was denied. How do I appeal?

A: You have a right to file an appeal with your insurance company by writing or calling the company. The company will contact you and review your claim internally. During that process you may submit additional information and appear in person.

Ultimately, if your company denies your claim after its internal reviews are finished, you may have the right to an external review. This is a review of your medical records by an independent review organization assigned by the Oregon Insurance Division.

For help at any time during this process, contact the Insurance Division's consumer advocates at 503-947-7984 or 1-888-877-4894. Or, read more detailed information at: Denied claims/appeals

Why is it taking so long for my insurance company to pay the doctor bills?

A: If the insurance company has all the information it needs, it must pay within 30 days of receiving a claim. However, if more information is needed, the company has additional time.

I received a fax offering insurance for my entire family for less than $400 monthly? Is this legit?

A: You should be very careful about unsolicited offers for low-cost health care. Many of these offers are scams or don't offer the level of coverage you think you're getting. Can you find the insurer's name on the advertisement? If you can't, it might be a scam because without a name you cannot verify that the company actually exists and its policies are being sold legally in Oregon. The Insurance Division consumer advocates can help you determine whether the company or agents are licensed in Oregon, and what the offer is all about. Call 1-888-877-4894.

What happens if I use an out-of-network doctor?

A: You could pay a lot more money if you don't use a doctor that agrees to bill the amount "allowed" by your insurance company. All insurance companies limit how much they will allow for any covered service. They then pay their share from this amount. In-network doctors, hospitals and other providers agree to accept the amount allowed by the policy as full payment. Out-of-network providers don't. Once your insurance company pays its share, you are responsible for the balance.

This balance is in addition to deductibles and coinsurance amounts you pay. Sometimes the insurance company pays the entire claim to you instead of paying the out-of-network provider. In that case, the medical provider can require full payment of all charges from you. To see an example of how much more you could pay to use an out-of-network doctor: Billing Process & Terms

What can I do if my insurance company denies my doctor's recommended treatment as not medically necessary?

A: Request a copy of any procedures your insurance company uses to determine medical necessity. You can file an appeal and follow review and appeal procedures, including an external review by an independent third party if necessary. Ask your doctor for supporting information to submit with your appeal. Your insurance company must use a medical professional to determine if a treatment is medically necessary. For more information on how to appeal, visit:
http://www.cbs.state.or.us/external/ins/consumer/appeals-guide/appeals-guide-toc.html

Why is my share of the medical bill higher than expected?

A: This could be for several reasons. For example:

• You used out-of-network doctors or hospitals that don't contract with your insurance company to give you a discounted price. These providers can bill you for the difference between full charges and the amount paid by your insurance. In addition to charging more, you may pay a higher percentage (coinsurance) if you go out-of-network. For example, you might pay 20 percent for an in-network provider and 40 percent for an out-of-network provider.
• Your policy doesn't cover some services you received.
• Medical complications added to your costs.
• Your annual deductible or coinsurance may not have been satisfied prior to the claim.

Is there any way I can find out what something costs before I get the care?

A: Many Oregonians can now visit their health insurance company website to find out in advance what they will need to pay for their next office visit, diagnostic test, or other common procedure. A law passed by the Oregon Legislature in 2007 requires insurance companies to provide their members with out-of-pocket cost estimates for common medical procedures through an interactive website and toll-free phone number. Insurers must provide estimates for the five most common procedures in each of these categories: office visits, radiology, laboratory, uncomplicated birth, immunizations, orthopedics, and digestive system endoscopy (a procedure that looks inside the body).

For example, if you need to schedule an office visit with your doctor, you can log onto your insurer's website to find out how much you would pay - or you can compare costs among doctors. You will see your co-pay, deductible, and other non-covered amounts for each doctor you select. Similarly, you can find out your share of the cost for a blood test, an X-ray, or a colonoscopy and compare the prices among providers.

The tool can also help you schedule surgeries, such as knee surgery or hip replacement surgery. Although the cost estimate does not include facility-related costs such as anesthesia, medical supplies, or operating room use, you can see the differences among providers. For example, costs will vary depending on whether you use an out-of-network or in-network doctor. In-network providers contract with insurance companies to provide discounts. Consumers typically pay significantly more to use non-contracted, or out-of-network, providers.

Someone from my insurance company told me my surgery was covered but, after the operation, the company wouldn't help pay. How can this be?

A: Often, advance information is incomplete. Final coverage decisions are usually based on details in the medical records. Discussions with an agent or company representative do not change how the policy covers a procedure. The company may, in fact, say that prior authorization isn't needed for a procedure. That doesn't mean it will cover the procedure. The procedure still must meet medical guidelines. Insurance companies have detailed, procedure-by-procedure guidelines on when coverage is allowed. You can ask for the guidelines for your particular treatment.

On the other hand, if prior authorization is required and obtained, the company may be required to cover the care you received.

Other reasons for coverage denials include changes in your coverage or enrollment status that you don't know about. For example, your employer may change insurance companies or benefit plans and this happens before you get a new insurance card. Or, perhaps your insurance ended sooner than you expected. Maybe the insurance company made a mistake.

For help getting an answer and information about a possible appeal, contact the Insurance Division's consumer advocates at 1-888-877-4894.

What is a pre-existing condition?

A: A pre-existing condition is a medical condition for which medical advice, diagnosis, care or treatment was received. For example, perhaps you visited your doctor and discussed your high-blood pressure. Even though you didn't get a prescription for medication, you may have received advice. If you're not sure, ask to see your medical records.

If you are age 19 or older, pre-existing conditions determine whether you can get a commercial health plan in the individual market (for people who don't get employer group insurance). Also, if you are 19 or older, you may have to wait before any pre-existing conditions are covered on an individual or group plan.

How far back in my health history do insurers look?

If you are age 19 or older, insurers look back on your health for a five-year period to determine whether to cover you.

If they accept you for coverage and you are 19 and older, they only look at the past six months of your medical history to see if there are pre-existing conditions they will not cover immediately. If you had pre-existing conditions in this six-month period, your insurer may not cover them for six to 12 months. However, if you had insurance before coming to the new plan - with no more than a 63-day gap in coverage - pre-existing conditions may be covered sooner or immediately.

What if I am under age 19?

If you are under age 19, federal health reform no longer allows insurance companies to deny you coverage because of pre-existing conditions or make you wait before coverage of any such conditions begins.