10 Tips for Working with your Health Plan
1. READ AND LEARN about the materials you receive from your health plan or employer.
These may include your service benefit plan, and a directory
of network providers. Many private health insurers send periodic newsletters and health promotion materials. These may help you better understand your benefits and your family’s services.
2. UNDERSTAND your health plan’s mission, vision and core values.
These statements generally include phrases about providing members with affordable, accessible care, forming working partnerships, and ensuring a member’s peace of mind. These statements can be useful when you are discussing service coverage. Frame your needs using the words your insurer has provided.
3. REQUEST A CARE COORDINATOR OR CASE MANAGER.
If your child has special health needs and requires ongoing services, ask your insurance if case manager or care coordinator services are available. This is a service that provides a single “go to” person to help you understand your benefits and make the referral or pre approval process easier.
4. REVIEW EXPLANATION OF BENEFITS (EOB)
Review every EOB you receive from your health insurer. Check for accuracy, the amounts paid, and any copayments you must pay. This is a good way to avoid billing mistakes.
5. BUILD RELATIONSHIPS with customer service personnel or case managers.
You may have a long-term partnership with your health insurance company, so it can be helpful to develop a trusting relationship that will benefit your child.
6. TALK TO THE PEOPLE WHO CAN HELP YOU THE MOST.
If the customer service person or your case manager can’t help you, ask to speak to the
person who can, such as a supervisor or head of the department.
7. THINK IN TERMS OF “MEDICAL NECESSITY.”
All health care insurance reimburses services based on “medical necessity.” Your health plan will have a definition for medical necessity in the service benefit plan. Frame your requests to reflect your insurance’s description of “medical necessity.”
8. KEEP A RECORD of calls and copies of all letters to your health insurer.
Write down the names and numbers of the people you speak with and a short summary of your discussion. If you have a problem getting a service covered, it is more effective to say, “I spoke with Ms. Smith on February 1, 2025, and she approved ….” Rather than saying, “The last time I called I spoke with someone, she told me…..”
9. USE YOUR RESOURCES.
If your insurance company refuses to authorize or pay for services after you have already submitted an internal appeal, you may be able to get help from the Office of Patient Protection (OPP). OPP may be able to conduct an external review, in which your health insurance’s decision is reviewed by an independent doctor or other professional. Call (800) 436-7757 for more information.
10. Contact Mass Family Voices
The Massachusetts Family-to-Family Health Information Center at the
Federation for Children with Special Needs is here to help.
Call 1-800-331-8688 or go to www.fcsn.org and complete an intake form.
Massachusetts Family Voices is a project of Federation for Children with Special Needs.
Funding provided by the U.S. Department of Health & Human Services, Health Resources & Services Administration, Maternal and Child Health Bureau, Division
of Services for Children with Special Health Needs, Grant #H84MC08005 to Massachusetts Family Voices @ the Federation for Children with Special Needs.