Frequently Asked Questions

By the State of Oregon Insurance Division

Q: How can I become an informed insurance consumer?

A: 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.

Q: My plan is a health-maintenance organization (HMO). How do I select a primary-care provider (PCP)?

A: 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 located.
• 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 insurance company.
• 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.

Q: What if I don't like my new primary-care provider (PCP)? Can I change to a different doctor?

A: 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 guidelines.

Q: Can I select my obstetrician/gynecologist (OB/GYN) as my primary-care provider (PCP)?

A: You may select a participating OB/GYN as your PCP if he or she has a contract with your insurance company to provide primary care.

Q: What can I do if my doctor says I need a medical procedure and my insurance company says it's not medically necessary?

A: 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.

Q: 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?

A: 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 your PCP.

Q: My doctor received prior authorization for a surgery that I had. Now my insurance company is denying my claim.

A: 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.

Q: What is "Oregon-based group coverage?"

A: 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.

Q: Do I have a choice of insurance companies when I elect portability?

A: 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).

Q: If I enroll in a portability plan within the 63 days allowed, when does the coverage begin?

A: It begins on the day following the termination of your group coverage. Your premiums also must be paid back to that date.