The best way to avoid the aggravation and anxiety that often accompanies a dispute with your health plan is to know your coverage and follow the health plan’s procedures for referrals and approvals.  Many disagreements between patients and their health plans occur because patients do not have a clear understanding about how their health plan works or which services it will cover.  You need to understand this information before a problem arises so you will be able to make effective decisions about your care and who will provide it. 

Evidence from states that track external review results indicates that many people do not understand the coverage that is provided by their health plans.  If you have not yet read all of your policy or the Summary Plan Description, read it now.  If a dispute does arise with your health plan, you need to understand what type of health plan you have in order to know what rights you have – in other words, what internal review requirements you and your plan must follow and whether you can use your state’s external review program.  These requirements may vary depending on whether you have coverage through your employer, or whether you purchased coverage on your own directly from a health plan (though you may have used an agent or an on-line broker to purchase the health plan) or an association-sponsored health plan.⁽⁶⁾

⁽⁶⁾ An association-sponsored health plan is one sponsored by a trade or professional organization or a business coalition.