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Frequently Asked Questions
Q1: How can I become an informed insurance consumer?
A1: Here are some ways to become an informed consumer:
- Review your member handbook, noting what is and isn't covered.
- Identify your family's needs. This may include specific medications
that they take, allergy treatments, physical therapy, well-child
examinations, immunizations, etc.
- Review the coverage and benefit limits associated with each
type of treatment. Find out if any of these services require
a referral to a specialist or prior authorization.
- Locate the grievance section of your member handbook. Know
your rights in having service denials reviewed.
- Talk to your insurance company's customer service department
about any questions you may have.
Q2: My plan is a health-maintenance organization (HMO). How do I
select a primary-care provider (PCP)?
A2: Here are a few important steps to help you get off to a good
start in an HMO.
- Call your plan to find out if your existing doctor is eligible
to be your PCP.
- Request a list of participating doctors from your insurance
company if you do not have an existing doctor or you need to
select a new one.
- Talk to friends, co-workers, or neighbors about their doctors.
Contact the medical society and hospitals for a listing of physicians
accepting new patients in your area. Find out if any of these
doctors participate with your insurance company.
- Identify a few doctors in the physician guide who are conveniently
- Call the physician's offices to verify that the physician
will accept you as a patient. Talk to the receptionist about
office policies. Find out office hours, how urgent situations
are handled, how long it will take to schedule an appointment,
and what hospitals the doctor will send you to.
- Once you have selected a physician, be sure to notify your
- The last step is to get established with your new primary-care
provider (PCP). A good way to get established is to schedule
a physical examination. Make sure the examination is covered
by your insurance company.
Q3: What if I don't like my new primary-care provider (PCP)? Can
I change to a different doctor?
A3: You can change your PCP at will. You will need to notify your
insurance company of the change. An insurance company may limit
changes to two selections in a 12-month period. Refer to your
member handbook or call your insurance company for additional
Q4: Can I select my obstetrician/gynecologist (OB/GYN) as my primary-care
A4: You may select a participating OB/GYN as your PCP if he or
she has a contract with your insurance company to provide primary
Q5: What can I do if my doctor says I need a medical procedure
and my insurance company says it's not medically necessary?
A5: You have the right to request a copy of any utilization-review
policy and procedures your insurance company uses to determine
medical necessity for your medical condition. You have the right
to file a grievance requesting reconsideration. Consult your doctor
and submit any additional important information with your grievance.
Your insurance company must have a medical doctor determine if
a treatment is not covered due to medical necessity.
Q6: My new HMO doctor will only refer me to a specialist within
her group of doctors even though the specialist that I have been
seeing for years is participating with my insurance company. What
are my options?
A6: You may not have a choice to go outside the clinic. It's important
to develop a good patient-physician relationship with your primary-care
provider (PCP) since he or she is responsible for your medical
care while enrolled in an HMO. If you are not comfortable with
this relationship, you may want to call the specialist office
who has been treating you to see which PCPs the specialist works
closely with. At this point, you'll want to verify that the recommended
PCP is participating with your HMO and verify whether you will
be accepted as a patient. Don't forget to call your HMO to change
Q7: My doctor received prior authorization for a surgery that
I had. Now my insurance company is denying my claim.
A7: Find out specifically why the claim was denied. Prior-authorization
determinations of coverage and medical necessity are binding for
30 days if obtained prior to the actual date of service. However,
eligibility determinations are binding for five days unless the
insurance company knows that coverage will end before then and
a termination date is known. You should exercise your grievance
rights once you know why the claim was denied. You also have the
right to seek assistance from the Insurance Division by filing
a formal complaint.
Q8: What is "Oregon-based group coverage?"
A8: For groups that purchase health insurance, the group policy
must be issued in Oregon. For example, if an employer has headquarters
in another state and has a national group policy, that policy
would not be Oregon-based. But if that same employer offers coverage
in a local HMO plan, that plan would be Oregon-based. For plans
sponsored by a "self-insured" group (in accordance with
federal provisions), the sponsoring group must be located in Oregon.
Q9: Do I have a choice of insurance companies when I elect portability?
A9: No. You must obtain coverage from the same insurance company
that provided your group plan, unless you qualify for portability
through the Oregon Medical Insurance Pool (OMIP).
Q10: If I enroll in a portability plan within the 63 days allowed,
when does the coverage begin?
A10: It begins on the day following the termination of your group
coverage. Your premiums also must be paid back to that date.
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