How Do I Navigate My Employee Insurance Benefits?
Updated: Nov 17, 2022
***Disclaimer: This article is for informational purposes only and does not provide medical, legal, or health advice and is not a substitute for mental health services
As the new year begins, now is especially important to get an understanding about what your work's health benefits - otherwise known as extended benefits- - includes and does not include. This article contains information about what you may want to investigate in terms of your plan. It is also important to note that each individual's plan is different so please verify your exact benefits by speaking with your benefit provider directly.
Look at your benefit booklet or review your plan online
If you have a benefit booklet at home, review it for coverage details about different categories (e.g. dental, medical, paramedical, assistive devices, coordination of benefits regarding coverage for spouses, children, etc.).
If you don't have a booklet at home, log in to your company's human resources page or employee website online to find more details about your specific plan. Your employer can direct you to the appropriate website if needed.
Call your benefit provider to ask questions
If you need clarification on coverage details you have reviewed, then it is best to call your insurance company to speak with an agent. Be aware though that wait times can be very long so it's best to call first thing in the morning on weekdays and/or when you don't have an upcoming meeting or other commitment in your schedule over the next hour or so to ensure you have enough time to devote to the call.
Once you're connected, the agent may be able to share more details about your plan, answer your questions, or give you some suggestions for how to proceed next.
Submit an estimate
The agent may encourage you to submit an estimate, which may require a medical prescription from a doctor indicating the need for the service or device, a medical form that your doctor has to complete with additional details about the item or service you require, as well as an official receipt that notes:
the date and cost of the service or item
the business and/or provider name
professional registration number (if relevant)
the length of the service
a cost breakdown
any other required information
Ask the agent to specify exactly what is needed for the estimate since you will want to include all of the necessary information – otherwise, your claim may be denied.
In terms of how to submit your claim, either send it in by mail (ask the agent if they recommend submitting original prescriptions/receipts) or upload the documents electronically to your profile via your insurance company’s website or phone application.
Keep your receipts
Keeping your receipts for insurance claims is important as you will need to retain a record of the expense in case the insurance company requires additional information or asks you to verity proof of expense on a later date. You will also need your receipt in case your claim is not approved and you wish to submit it as a medical expense when you do your annual taxes.
Follow the insurance company's appeal process (if needed and available)
If your claim is denied and you want to request a second review, you can ask the agent to explain what is needed and/or look at the insurance website for more details. There is no guarantee your claim decision will be overturned but, if you feel strongly enough, it is worth asking if they will consider your request to appeal along with examining any additional medical documentation you may need to provide.
Wishing you well on your journey.
Davina Tiwari MSW, RSW, CSFT
Registered Social Worker and Certified Solution Focused Therapist
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