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Patients: Find Answers to Your Health Care Questions

There are numerous reasons why your health insurance company or health plan may not cover services under your health insurance policy.

    > Pre-Existing Conditions: Exclusions for conditions that existed prior to coverage.

    > Waiting Periods: Waiting periods (e.g. 12-24 months) for services related to conditions existing prior to the plan becoming effective for that patient.

    > Restrictive Benefits: Some services are covered only if they are provided immediately after hospitalization. Some health insurers have severe limitations on the numbers of visits, providers or types of services covered.

    > Medical Necessity Criteria: Health insurers may require preauthorization for services, or deny coverage as "medically unnecessary." In some cases, these denials may be appealed through your insurance company or to the North Carolina Healthcare Review Program.


NORTH CAROLINA HAS SEVERAL RESOURCES TO HELP RESOLVE THESE QUESTIONS!

    (1)The Managed Care Patient's Assistance Program:

    Attorney General Roy Cooper has announced the Managed Care Patient Assistance Program (MCPAP). Patient Assistance Specialists are available to provide advice to consumers, caregivers, and providers about insurance and managed care issues including benefits, grievances, appeals, and external review processes. Created as part of the North Carolina Patients' Bill of Rights in 2001, the Managed Care Patient Assistance Program acts as an intermediary between patients and health insurers and can assist providers with reimbursement and utilization review issues. MCPAP can also answer general questions about health insurance, HMOs, and prior approval processes. Contact the Managed Care Patient Assistance Program (919) 733-MCPA (6272) or via email at [email protected]. The toll free number is (866) 867-MCPA (6272).

    (2) The North Carolina Department of Insurance Managed Care--Consumer Division:

    The Goal of the Consumer Services Division is to respond to questions and complaints concerning insurance and to provide consumers with alternatives and courses of action to solve a particular insurance problem. NCDOI can forward your complaint to the insurance companies, obtain information or explanations on your behalf from the insurance companies and explain your options. NCDOI Consumer Services can be reached at: 1-800-546-5664.

    (3) Self-Insured Employers:

    If you are insured as a result of your or your spouse's employer, your rights under your health plan may be governed by the Employee Retirement Income Security Act (ERISA) under the U.S. Department of Labor. If so, state law will not generally apply to your group health plan. Instead you will need to contact the U.S. Department of Labor for consumer information and assistance. The law requires that your plan sponsor provide you with a "summary plan description". The employer may also be able to overturn a decision of the plan administrator, especially with regard to a medical necessity determination. Contact: 1-866-4-USA-DOL or http://www.dol.gov/dol/topic/health-plans/index.htm.