Dealing with insurance coverage can feel overwhelming, but taking proactive steps can help you avoid common pitfalls and ensure you get the care you need. Whether you're scheduling routine care or facing a complex medical situation, these practical strategies will help you work effectively with your insurance company, understand your benefits, and protect yourself from unexpected costs or coverage denials.
Before Receiving Care
- Verify Your Coverage: Review your Summary of Benefits and Coverage document to understand your benefits, exclusions, deductibles, and cost-sharing requirements
- Confirm Provider Network Status: Always verify that healthcare providers are in your insurance network before receiving care—check with both the provider's office and your insurance company
- Understand Prior Authorization Requirements: Ask your provider which services need pre-approval and confirm they've obtained it before proceeding with treatment
- Request Cost Estimates: For planned procedures, ask your provider and insurance company for cost estimates to help budget for expected out-of-pocket costs
- Get Important Confirmations in Writing: When your insurer confirms coverage, ask for written confirmation via email or letter
During the Process
- Keep Detailed Records: Document all communications about authorization requests, including dates, names of representatives, and reference numbers
- Follow Up Regularly: Don't assume requests are being processed—check on status frequently
- Plan Ahead: Schedule services with enough lead time to complete authorization processes before urgently needing care
- Ask Questions: If you don't understand requirements, ask insurers to explain their criteria and what information they need
If Problems Arise
- Check for Technical Issues: Sometimes denials result from simple issues like name mismatches—review all information for accuracy
- Be Prepared to Appeal: Most people don't appeal denials, but those who do have a high success rate
- Know Your Rights: Understand Connecticut's timeframes and requirements for insurers' responses to requests
- Get Help: The Office of the Healthcare Advocate can assist with authorization denials, delays, and navigation challenges
The Office of the Healthcare Advocate can assist if you encounter problems with prior authorization denials or delays, helping ensure you receive timely access to necessary care. We offer outreach seminars to both consumers and healthcare providers to help you better understand how to navigate the prior authorization process with insurance carriers.
For the best outcomes when working with the Office of the Healthcare Advocate, contact us early before deadlines expire, provide complete information including denial letters and communications, follow our experienced advocates' recommendations, stay actively engaged throughout the process, and share your feedback to help us identify systemic issues. These proactive steps can help prevent many common insurance problems and position you for success when challenges arise.