Getting the Most from Your Health Insurance

Understand Your Coverage

• Review your Summary of Benefits and Coverage (SBC).
• Verify coverage before receiving services, whenever possible.
• Obtain a cost estimate before receiving non-emergency care.
• Know whether your providers and facilities are in-network.
• Determine which services require prior authorization.
• Understand how diagnosis codes, billing codes, medical necessity, and documentation affect coverage decisions.
• If coverage is denied, determine whether the denial is due to missing information, an administrative issue, or your plan's coverage policies.

If You Have Coverage Problems

• Determine whether the concern can be resolved before filing a formal appeal.
• Learn the deadlines and steps for filing an appeal.
• Keep records of phone calls, reference numbers, bills, payments, Explanation of Benefits (EOBs), and key documents.
• Identify the policy or documentation supporting a decision.
• Request important decisions or explanations in writing.
• When you find a helpful representative, write down their name and, when appropriate, ask to speak with that person if you need to call back.
• Request a case manager or other specialized support for complex healthcare needs.
• Stay engaged until your concern is resolved or you understand your next steps.

Make the Most of Your Benefits

• Compare out-of-pocket costs across in-network facilities.
• Review your EOB before paying a medical bill.
• Explore preventive services, wellness benefits, incentive programs, telehealth, nurse advice lines, and other covered services.
• Check whether complementary therapies, nutrition services, or other support services are covered.
• Verify prescription coverage, preferred pharmacies, mail-order options, and lower-cost formulary alternatives.
• Use your health plan's website or app to track claims, benefits, referrals, and prior authorizations.
• Check whether your plan covers second opinions for complex diagnoses or major procedures.
• Review your plan during open enrollment to make sure it meets the needs of everyone on the plan. Compare plan costs, provider networks, and covered services.

Questions to Ask Your Insurance Company

These questions can help guide conversations with your insurance company. Not every question will apply to every situation. Consider the questions that are relevant to your situation.

• Can you show me where this information is documented?
• Can you explain how you reached this decision?
• Why was this service denied?
• What additional or corrected information could change this decision?
• What is the next step if I disagree with this decision?
• What are my appeal options if coverage is denied?
• Is prior authorization required?
• How is medical necessity determined?
• Are there lower-cost covered alternatives?
• Does my insurance plan offer support services for people with complex health issues?

Still need help? If you have exhausted your health plan's customer service and appeals process, consider contacting your state insurance department, a consumer assistance program, or your elected official's constituent services office to explore additional options.

The federal Uniform Glossary of Health Coverage and Medical Terms, published by the Centers for Medicare & Medicaid Services (CMS), explains terms such as deductible, copayment, coinsurance, prior authorization, appeals, and out-of-pocket limits. Access the resource at https://www.cms.gov/files/document/uniform-glossary-english-060723.pdf (opens in a new tab)