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Top 5 Common Concerns

My insurer has not paid my claim and it’s been months. The provider has turned me over to a collection agency. What should I do?

You need to determine what type of health coverage you have since the state does not have jurisdiction over all types of health plans. Once you verify what type of plan you have from the below table, then make contact with the appropriate entity associated with that health plan.

If you are covered under

Contacto

Individual or group policy issued in Florida

Submit an insurance concern with our office.

 

Medicare or Medicare Advantage Plan

Call Medicare at 1-800-633-4227.

Medicaid

Call the Agency for Health Care Administration at 1-877-254-1055 or online at http://ahca.myflorida.com.

 

Self-insured city, county, or state group health plan

Contact the human resources office of the governmental entity for assistance.

Self-insured employer

Speak with the employer first. If the claim not resolved, contact the US Department of Labor at 1-866-444-3272.

Individual or group policy issued outside of Florida

Contact the state department of insurance where the policy was issued. Contact information can be obtained from https://content.naic.org/consumer.htm.

 

My individual health policy was cancelled and now I have no coverage. What can I do?

If your health policy cancelled for non-payment of premium and you believe the full premiums were paid timely, submit a insurance concern with our office. If you did not pay the full amount due by the end of the grace period and the policy lapsed for non-payment of premium, you will need to wait for the next open enrollment period to obtain a new policy effective January 1. Under the Affordable Care Act (ACA), you may qualify for a Special Enrollment Period to enroll during the year. Please contact the federal Marketplace at 1-800-318-2596 to inquire if you qualify.

What do I do if my insurer will not authorize a procedure or prescription drug my physician says I need?

If your insurer refuses to pay a claim or denies pre-authorization for a service, you have the right to appeal the decision. Insurers must tell you why they’ve denied your claim or pre-authorization and they must let you know how you can dispute their decision. There are two ways to appeal an insurer decision, either by requesting an internal appeal or external review. You will need to exhaust the internal appeal process before applying for an external appeal. Your physician should be able to assist you in filing the appeal or by providing you with the necessary medical documentation to substantiate the need for the procedure or specific prescription drug.

If your health plan does not provide you with your appeal rights, submit an insurance concern with our office.

My insurer paid a portion of my claim from an out of network provider/facility/air ambulance but now I am being balance billed for the difference. Am I responsible for paying this amount?

There are several factors involved that will determine if you owe the provider/facility or air ambulance. Florida balance billing protections apply only to health insurance and HMO contracts issued in the state. If your policy was issued outside the state of Florida, contact that state’s insurance department for assistance. If you are covered under a self-insured employer plan or a city, county, or state governmental plan, contact the employer for assistance.

Florida individual and group health plans and HMO contracts:

Provider is Located

Date of Service

Contacto

Within Florida Any date of service Submit an insurance concern with our office.
Outside Florida Before January 1, 2022 For HMO contracts, submit an insurance concern with our office. For other types of plans, contact your health plan for assistance. If the claim is not resolved, you will need to negotiate the balance due or payment schedule with the provider.
Outside Florida On or after January 1, 2022 Contact the No Surprises Act Help Desk at 1-800-985-3059 or file a complaint online at
https://cmsitsm.servicenowservices.com.

 

I was enrolled in a Marketplace policy that I did not authorize. How did this happen and how can I get the policy cancelled?

Many times we are not able to determine how an agent obtained an individual’s personal information. To get the policy cancelled and find out the name and National Producer Number (NPN) of the agent who submitted the application, contact the federal Marketplace at 1-800-318-2596. Advise their office that you did not apply for a policy or authorize an agent to obtain a policy for you. The Marketplace customer service representative will ask for the information their office needs to get the policy cancelled. In addition, obtain the name of the insurer and the agent name with the NPN who wrote the policy so you can submit an insurance concern with our office. Our office will open an investigation on the agent and seek administrative action against his/her license, if possible.


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