If you received a claim summary and don't understand what it means, we're here to help.
- Find out why we made the decision to pay or not pay a certain amount.
- Get details about the benefits your health plan covers.
- Ask for the diagnosis and treatment codes your provider used to bill us, and what they mean. We'll provide these at no cost to you.
Your Questions Answered
We do everything we can to make sure we’ve paid your claim the right way, based on your benefits. If you don’t agree with the decision we made, you have a right to tell us why and ask us to reconsider. This is called an appeal (sometimes we call it a grievance). Everyone has the right to an appeal, but the type of plan you have makes a difference in how those rights work.
Contact us and we’ll walk you through the process and paperwork needed.
Here are some important things to keep in mind:
- You must ask for an appeal within 180 days of getting a claim denial (unless your Evidence of Coverage says you have more time.)
- We’ll give you an answer within 15 to 60 days of getting your appeal – depending on your health plan rules.
- If waiting will stop you from getting urgent care you need, tell us and we’ll give you an answer within 72 hours.
- You can file an appeal yourself, and we’re here to help if you have questions. But if you think you need extra support, you can choose to work with a representative – like a lawyer – to help you file your appeal or file a civil lawsuit.
- You may begin an external appeal with an outside agency at the same time we’re reviewing your appeal if you need care urgently or you are getting ongoing care.
If you think you need extra help from an outside agency, there are Consumer Assistance Programs available to help you. They can tell you about your rights and assist you in filing a grievance.
You'll need to contact the agency that works with your type of plan. Not sure what type of plan you have? Contact us.
- Non-Federal Government Fully Insured and Self-Funded Plans: U.S. Department of Health and Human Services Health Insurance Assistance Team (HIAT) - 1-800-393-27891-800-393-2789
- State of Tennessee Insurance Program (State of Tennessee employee plan, higher education, local education and local government plans):
State Division of Benefits Administration - 1-866-579-00291-866-579-0029 - All other Self-Funded plans:
U.S. Department of Labor's Employee Benefits Security Administration (EBSA) - 1-866-444-32721-866-444-3272 or www.askebsa.dol.gov - All other Fully Insured plans:
Tennessee Department of Commerce and Insurance (TDCI) - 1-800-432-40291-800-432-4029 or visit online.
You can find more details about your Rights and Responsibilities here.