Resolving Claims Issues

Submitting and processing medical claims doesn't have to be a complicated task. Most claims are submitted correctly by providers, processed accurately by the health plan administrator, and paid in a timely manner. Occasionally a dispute may arise as to the eligibility for coverage and/or the handling of a particular claim submission; here are a few tips on how to resolve claims issues:

  1. Whenever you have a question or concern regarding a claim or billing, contact your health plan Member Services department first. They can determine the best course of action and contact person for resolving your issue, depending on what is taking place with your claim.
  2. Don’t ignore a bill or notice from a health care provider – Verify with your health plan Member Services whether or not they have received the bill and if they have received it, what is the status of the claim. If the bill hasn’t been received, take the necessary steps to ensure the plan receives a copy of the bill in order to consider payment.
  3. Don’t panic upon the receipt of an initial claim denial - Claims that are denied by the plan may be appealed by the submission of additional information or supporting documentation and/or a written request for reconsideration. If you have a claim that has been denied, contact the health plan Member Services directly to inquire about the appeals process.
  4. Always document your conversations with health plan staff – write the telephone number you called, the date and time of the conversation, the name of the person you spoke with, and what was said in the conversation. This may help you later.

Appealing Claims Decisions

PPO Health Plans

PPO participants have the right to appeal any claim denied by the PPO Claims Administrator.  There are two levels of appeals, as set forth in the PPO Plan Documents:

1) Level One Appeal - The participant submits an appeal to PPO Claims Administrator within 60 calendar days from the claim payment date or the date of the notice of denial of benefits.  The appeal must state in clear and concise terms the reason or reasons for the participant's disagreement with the determination, and should include any additional documentation supporting the appeal.

2) Level Two Appeal - If the participant is dissatisfied with the PPO Claims Administrator's Level One appeal decision, he/she may submit a written request for a Level Two appeal to the County of Orange - Employee Benefits within 60 calendar days of receipt of Level One appeal denial.  The participant will be required to submit a signed HIPAA release form.  Employee Benefits will review all documentation pertaining to the Level Two appeal and make a final determination.

The Employee Benefits Office cannot consider an appeal until the participant has exhausted hi/her appeals efforts through the PPO Claims Administrator.

Participants with questions about their appeals rights should contact the PPO Claims Administrator.

HMO Health Plans

HMO participants must contact the health plan Member Services directly. Additional information about the appeals and grievance process can be found on the plan website.