Know your health plan
- Does your health plan have network providers?
- Does your health plan let you visit out-of-network providers?
- What are the deductible, copay or coinsurance amounts? When do you need to pay them?
- Do you need a referral or pre-authorization before you can get treatment?
Talk to your medical provider
- Confirm with both your health plan and medical provider that they're part of your plan's network.
- Ask your medical provider how they collect your deductible, copay and coinsurance, and how they bill for services.
- Network providers bill your health plan directly. Out-of-network providers don't have to bill your health plan, so you may need to ask your insurer to pay you back.
Review your bill and the Explanation of Benefits (EOB)
- Network providers: Compare your bill with the EOB and pay what your health plan says you need to.
- Out-of-network providers: Contact your health plan for claim forms and due dates. You may have to pay the provider and ask your health plan to pay you back. If possible, ask your health plan how this works before paying your provider.
- Sometimes an out-of-network provider must bill your plan and can't charge you for what your plan will pay for. Learn more about balance billing.
Claim problems or disagreements
- Read your health plan contract to see what it covers and how to appeal decisions.
- Contact your health plan and provider. Try to resolve the problem before filing an appeal.
- If you can't resolve the problem, file an appeal with your health plan.
- Keep track of due dates to submit your appeal documents.
You can also file a complaint with us. Filing a complaint doesn't take away your right to appeal.