IDENTIFYING YOUR HEALTH INSURANCE COVERAGE TYPE

…can go a long way in framing the conversation about it with your provider regarding questions or issues related to coverage, claims and clauses.

Start here:

1. Are you, or your family, signed up for a plan that your employer offers to the employees at your workplace, or that you buy through an association?

If yes, then you have a group plan.

2. Do you have insurance through a public or government offered program?

For example: Medicare, Basic Health, Apple Health for Kids or another kind of state or federally-sponsored program?

If yes, then you have a government-sponsored plan.

3. Do you have a policy that you, or a family member, buy directly from an insurance company (HMO, PPO)?

If yes, then you have an individual plan.

If you have any of the policies listed below, contact your insurance company to learn what appeal process might be available for you since these policies are not recognized as health plans by Florida State.

  • Long-term care insurance
  • Medicare supplemental coverage
  • Limited health care services
  • Disability-income insurance
  • Coverage provided from an auto or homeowner personal injury claim
  • Worker’s compensation coverage
  • Accident-only
  • Fixed-payment indemnity or
    mini-med insurance
  • Critical illness coverage (a policy for serious illness, like cancer)
  • Dental- or vision-only coverage
  • Short-term limited purpose insurance (for example, student coverage)

NEXT, IS YOUR ISSUE PRE-SERVICE OR POST POST-SERVICE?

If you received a denial from your health plan because:

  • It refused to pay your medical provider for all or some of the care you’ve already received; this is called a post-service determination.
  • It denied approval for treatment you’re currently receiving ― or for treatment your medical provider recommends ―this is called a pre-service determination.

If you have a pre-service issue and it’s an urgent medical situation, you may qualify for a shorter turnaround time on your appeal.

IS YOUR HEALTH ISSUE URGENT?

If your situation’s urgent, your health plan will decide your appeal faster than if it’s a non-urgent issue. This is called an expedited appeal.

YOU CAN FILE AN EXPEDITED APPEAL IF YOU:

  • Are currently receiving or you were prescribed to receive treatment; and
  • Have an urgent situation. Urgent means a medical provider believes a delay in treatment could seriously jeopardize your life or overall health, affect your ability to regain maximum function, or subject you to severe and intolerable pain.
    Or
  • Have an issue related to admission, availability of care, continued stay, or health care services received on an emergency basis and have not been discharged.

YOU CANNOT FILE AN EXPEDITED APPEAL IF YOU:

  • Already received the treatment and are disputing the denied claim, or
  • Your situation is not urgent.

WHO DECIDES IF YOUR SITUATION IS URGENT?

A medical provider with knowledge of your medical condition or the Medical Director for the Insurer.

HOW DO YOU FILE AN URGENT APPEAL?

You – or your authorized representative – may file your expedited appeal with your health plan verbally.

As of Jan. 1, 2012, your health plan – provided it’s not grandfathered – must respond as soon as possible, preferably within 24 hours, but no longer than 72 hours. They may deliver their response verbally, but must issue it in writing no later than 72 hours after the verbal decision. You may even have the option to request a review from a certified independent review organization (apps.leg.wa.gov) before your health plan’s internal review is complete.

If you need to file an urgent appeal, we suggest you, your authorized representative, or your provider call your health plan immediately.

You can read more on the topic of health insurance coverage and claims here!

Here are some resources on the topic specific to Florida State Health Insurance Coverage:

Florida office of Insurance Regulation

How to contact the Florida Dept of  Insurance and Insurance Commissioner?

Florida Dept of Financial Services 

Remember not to leave anything to chance when it comes to your Health Insurance Claims and Coverage. Feel free toreach out to us if you have any questions, comments or concerns regarding your particular situation.