• 10 Tips to Help You Understand Your Coverage under Your Managed Care Health Insurance Plan
• Consumer Assistance - Managed Care Health Insurance Plans
• Do You Need Help With a Request or an Appeal for Coverage of a Prescription Drug?
• Helpful Coverage Tips for Parents of Special Needs Children
• MCHIP Appeal Process
• Tips to Help You Appeal a Denial From Your Managed Care Health Insurance (MCHIP)
• Tips to Help You Appeal an Experimental or Investigational Service Denial by Your MCHIP

The Office of the Managed Care Ombudsman was established in 1999 under §38.2-5904 of the Code of Virginia. The Office helps Virginia consumers whose health insurance is provided by a Managed Care Health Insurance Plan (MCHIP), such as a Health Maintenance Organization or a Preferred Provider Organization. The principal responsibilities include the following:

Protecting the interests of consumers whose health insurance is provided by a MCHIP by:

• Assisting consumers in understanding their rights and how to resolve problems.
• Answering inquiries from consumers, health care providers, and other individuals.
• Providing information on MCHIPs, types of MCHIPs, mandated benefits, utilization review procedures and available appeal options.
• Assisting consumers in filing appeals, including utilization review appeals.
• Ensuring consumers have access to the Office and receive timely responses.

Help from the Office of the Managed Care Ombudsman:
If you are a consumer and would like assistance in appealing an adverse decision rendered by an MCHIP, you can initiate contact with the Office as described above. In order for the Office to formally help you file an appeal, you will need to complete a Life and Health Insurance Complaint/Appeal Form which documents your written authorization. We suggest you call the Office prior to completing the form. If your problem is outside the scope of the Office, the staff will refer you to another section or agency for assistance.

General Questions

• How can the Bureau of Insurance assist me?
• Should I ask for assistance from the Office of the Managed Care Ombudsman?
• What should I know about my coverage and my rights to appeal?

How to Appeal a Denial

• What are the steps of a typical appeal process?
• How do I appeal a denial from my Managed Care Health Insurance Plan (MCHIP)?
• How do I get help with a request or an appeal for coverage of a prescription drug?
• My MCHIP has denied payment for my requested service because it says the service is experimental/investigational. What is the best way to appeal this decision?
• Standard Internal Appeal Process Flowchart
• Urgent Care Internal Appeal Process Flowchart

Miscellaneous

• What are Mandated Benefits/Offers?
• View Current Annual Report of the Office of the Managed Care Ombudsman
• Life & Health Tips, Guides & Publications

Contact Information for the Managed Care Ombudsman:
If you are a consumer, health care provider or other individual with a general question or have an inquiry regarding MCHIPs, managed care, health insurance or related subjects, you can contact the Office of the Managed Care Ombudsman.

Toll free phone 1-877-310-6560, select option 1
Fax (804) 371-9944

Office of the Managed Care Ombudsman
Bureau of Insurance
P.O. Box 1157
Richmond, Virginia 23218
ombudsman@scc.virginia.gov

Office of the Managed Care Ombudsman

Helpful Coverage Tips for Parents of Special Needs Children

Do You Need Help With a Request or an Appeal for Coverage of a Prescription Drug?

Tips to Help You Appeal an Experimental or Investigational Service Denial by Your MCHIP

1. It is well worth your time and effort to read thoroughly and understand as much as you can from documents provided to you by your Plan. This includes your Evidence of Coverage, as well as other documents such as Member Handbooks, Provider Directories, Newsletters, and any other material provided by your plan.
2. Know as much as you can about how your plan works before you need to use it. It is most important to know beforehand about such things as selecting a primary care provider, obtaining referrals to specialists, copayment requirements, and access to emergency care. Realize that your plan will probably not cover all of your medical expenses, and that you may have to pay part of the cost.
3. Ask questions about anything that is not clear, confusing, or that you do not understand.
4. If you need assistance, talk with your plan's representatives, your agent, your employer, or contact the Office of the Managed Care Ombudsman.
5. If a problem arises, you should first contact your Managed Care Health Insurance Plan. Your evidence of coverage contains a telephone number and mailing address for your use in contacting the plan. Be sure to record the day you call, the name of the person you speak with, the title of the person you speak with, and a summary of the conversation.
6. If you or your physician have difficulty obtaining approval for medical care, or if you experience difficulty with a claim, know what your rights are according to your particular plan.
7. Understand your right to appeal decisions made by the plan that are not in your favor (an "adverse decision"), and follow the instructions provided by your plan to appeal an adverse decision. You need to familiarize yourself with the various levels of appeals and grievance procedures that are available to you directly through your plan.
8. If you write a letter to your plan to file an appeal or a grievance, document the facts that support your case. Keep your letter business-like and clearly state why you believe you are correct. Include any supporting documents from you or your physician that support your appeal or grievance.
9. Follow the time lines established by your plan for filing any appeals, grievances or complaints. Record the date you provide information to your plan, and be sure to keep a copy of any letters you send to your plan.
10. At any point in the process, you can contact the Office of the Managed Care Ombudsman for assistance.

Tips to Help You Appeal a Denial From Your Managed Care Health Insurance (MCHIP)

Managed Care Health Insurance Plan Problems and Questions

If you have experienced a problem with your Managed Care Health Insurance Plan (MCHIP), or if you have a question regarding your MCHIP, you should first contact your MCHIP for assistance. Contact information is provided on your insurance card and also in documents the MCHIP provides to you such as the evidence of coverage. Usually the MCHIP can answer your question. If you do not understand your MCHIP's response, disagree, still have questions or are uncertain about something, contact this office for help.

If you have an informal question or concern, you can contact us for assistance by calling toll-free 877-310-6560 or if you're in the Richmond metropolitan area you can contact us at 804-371-9032. You can also write to us at Office of the Managed Care Ombudsman, Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218. Our fax number is 804-371-9944. You can also contact us via electronic mail at ombudsman@scc.virginia.gov We will respond to your question or concern related to your MCHIP or to managed care.

If you would like this office to formally assist you appeal an adverse decision that your Managed Care Health Insurance Plan (MCHIP) has made, then please complete a Life and Health Insurance Complaint/Appeal Form. When you return the form, please include copies of any denial letters you have received from your MCHIP. This office will then assist you in the appeals process, and make sure that you understand your rights. If necessary, we will contact your MCHIP to clarify any issues related to your appeal that are not clear or that are in dispute.

Consumer Assistance Services/Consumer Outreach and Education Guide. This consumer guide should be used for educational purposes only.