Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274
Hours of Operation: Monday-Friday 8:30 AM – 5 PM Eastern Time
Website: https://www.patientadvocate.org/connect-with-services/
https://www.patientadvocate.org/migrainematters/
Case Management Services,
This division of PAF offers one-on-one personal advocate services to patients battling serious disease. Their staff helps seek out options to overcome insurance denials, healthcare access issues and medical debt crisis challenges.
Pre-approval for prescriptions
Pre-authorization is often needed for expensive medicines. Sometimes insurance plans will want you to try a different medicine before they will approve the one your doctor prescribes. They may also limit how much of the medicine you can have at a time, or how many refills you can have. If your health care provider thinks that the insurance plan’s preferred medicine wouldn’t work or wouldn’t be safe for you, you can appeal the decision.
For further information:
Pre-approval for emergency care
The Affordable Care Act states that pre-authorization cannot be required for emergency care. This is true whether the care is provided by an in-network or out-of-network health care provider or hospital. And if you need to get emergency care in an out-of-network hospital, your insurance plan can’t make you pay more than you would in a network hospital.
But be sure to find out what your insurance plan considers emergency care. Many insurance plans provide resources to help you figure out what’s an emergency that needs to be treated in an emergency department.
Need more information?
US Department of Health & Human Services
Website: www.healthcare.gov
For the most up-to-date information on health care and insurance laws and how they might affect you.
National Association of Insurance Commissioners
Toll-free Number: 1-866-470-6242
Website: content.naic.org
Offers contact information for your state insurance commission. You can contact your state insurance commission for insurance information specific to your state, or report problems with your insurance company.
Medicare Rights Center (for those with Medicare)
Toll-free number: 1-800-333-4114
Website: www.medicarerights.org
If you can't resolve your problem directly with the health plan
If your claim is still denied after internal and external appeals, ask the health care provider if the cost of the bill can be reduced. Many providers are willing to reduce bills to get paid faster.
If none of these steps work, you might have to take your appeal to a government body.
It helps to know who regulates a health plan. You can talk to the government group that regulates the health plan to find out if they can offer more information or extra help.
- Private group plans (or fully insured plans) purchased by employers as a benefit for employees are usually overseen by the state’s insurance commissioner or department of insurance. You can find your state’s insurance department by contacting the National Association of Insurance Commissioners.
- Self-funded plans (or self-insured plans) are health plans that employers or unions create just for their employees and families. They are overseen by the US Department of Labor’s Employee Benefits Security Administration. Ask your employer if you’re not sure whether your employer is self-funded.
- Individual plans sold through the health insurance marketplaces are regulated by a marketplace board in each state. This state board oversees the marketplace and the plans sold by it.
- Managed care plans are regulated by several state and federal agencies. Your state insurance commissioner or department of insurance can provide specific information about a plan.
- Medigap policies (Medicare Supplement Insurance policies) are overseen by federal agencies, as well as some state laws. Contact the Centers for Medicare and Medicaid Services (CMS) and/or your state department of insurance for information.
- Medicaid and CHIP are joint programs that are controlled by your state health department and the federal Centers for Medicare and Medicaid Services.
- Medicare is run by the federal Centers for Medicare and Medicaid Services.
- TRICARE is overseen by the US Department of Defense.
- The Veteran’s Health Administration is regulated by the US Department of Veteran’s Affairs.
- Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is run by the VA Chief Business Office Purchased Care.
