So many great things are associated with the beginning of a new year, and 2021 may be the most anticipated new year of the century. A return to life-as-we-knew-it on the horizon. The hope and promise of changes we’re planning for ourselves and our families. Changes in Washington. And dare we say it — brick-and-mortar school? Of course, nothing generates excitement and anticipation like the prospect of a new year of coverage on your family’s health plan. (Mostly just kidding!)

If your child’s benefits plan turns over with the beginning of a new calendar year, you have the opportunity to turn over a new leaf and start 2021 with a resolution to gain more knowledge around benefits and renew your zeal for filing out-of-network claims. 

So make time to dive in and read up! Party hats and noisemakers optional.


Review Those Shifty Deductibles

Has the deductible increased? What about your share of cost? Compare your calendar year 2020 benefits and coverage with what is on tap for the new year. Ask yourself:

  • Is pre-authorization required for such services as acupuncture and chiropractic care, and the big four for our kids: OT, PT, speech, and ABA?
  • Has your share of cost seen an uptick? For example, is your 80% coverage now at 60%?
  • Don’t overlook plan details that cover the dentist and trips to the pharmacy. Make sure you know what you’re opting into and out of for filling teeth and prescriptions.

Read Those EOBs

The EOB, or explanation of benefits, is the paperwork that comes in the mail for claims filed by you or by your child’s provider. Start thinking of the EOB as a roadmap to the financial story of every medical encounter you have AND the mechanism by which to pursue correct payments.

EOBs are too often — and see if you recognize your pattern here — tossed in the junk drawer, used as coasters for coffee cups and wine glasses, or put into neatly labeled file folders and left to gather dust. But EOBs contain information you need to be on equal footing with your health plan, so don’t toss these envelopes aside! If you have filed correctly and your out-of-network deductible isn’t astronomical, some of the envelopes you receive may contain checks. But every envelope contains valuable information. 

Don’t trust the health plan to get it right. If you are reading your EOBs you can sometimes catch the plan red-handed. They do indeed make mistakes.

File for Dollars

There can be multiple ways to file claims. Regardless of how you file, retain a copy of everything you submit at least until processing is complete.

  • If you’re someone who likes to have a paper trail, you can always file your claims by mail. Look online at the health plan website for a blank claim form. Save time by creating a master claim form with all the basic unchanging demographics entered.
  • Check to see if faxing your paper claim is an option. Filing by fax saves mailing time and postage — and it also creates a handy record. If you’re able to fax, always remember to print a transmission receipt with the correct date stamp. 
  • Many people prefer to file using their health plan’s website message center, online chat, or by email, and this option is becoming available for more and more health plans. In addition to saving mailing time and postage, you will get a response message acknowledging receipt of the claim you’ve filed. If you’re using the chat feature, you have the additional benefit of being able to refer back to the saved record of these conversations with your plan’s customer service representatives. 

But regardless of how you file, remember to use the member website to monitor your claims processing. You can confirm that processing has begun and also see processed claims sooner, thus catching any potential problems sooner, too.

Know Your Benefits

If you aren’t aware of this already, I’m sorry to be the one to tell you that many health plans put an annual limit on the number of occupational, physical, and speech therapy sessions they will cover depending on diagnosis. Some plans authorize 24 per year, and some provide 30 or 50. If your child has more than one of these services, find out if the per-year limit is combined between services or if there is a separate accumulator per service: i.e., 30 for OT, 30 for PT, and 30 for speech. If you can, call for pre-auth early, and keep your child’s therapy team in the loop on any documentation required.

Read the Hidden Benefits

It’s not often that health plans give more than they cost, but be alert to coverage or discounts for weight-loss and fitness programs and alternative medicine.

Know When to Submit

Filing limits vary by plan. Don’t let your claims “age out” of the payment window. The typical window for Cigna can be as short as 6 months from the date of service. Blue Cross and Blue Shield vary from 12 months to 15 months or even 18 months.

Leap into the Breach and Call

Have you discovered a problem with your submitted claim? No big surprise there! Now it’s time to communicate with the plan.

So let’s prepare for those customer service calls.

  • If you can, avoid calling on Monday, as this is generally the busiest day of the week and lunch time the busiest hour of any day. Try the earliest or latest hours or weekend times if available.
  • Be ready to take notes. Have pen and paper, device, or laptop handy and all the info you need from your EOB.
  • Always always note the date of your call and get a name and a call reference number. Every call generates a reference, but you have to know to ask for it. Check the plan website to see if live chat or a customer service message center are options on your plan.  

Holding your health plan accountable for accurate reimbursement is good for your financial health and (despite short-term frustration) can in the long run reduce stress and anxiety and impart a sense of control. You may not always like what the plan is paying, but you need to understand how they are paying. 

So happy almost 2021! Let’s make this the year that you stop being part of the percentages that the plans count on to just give up and go away!


Leslie Lobel

Director of Health Plan Advocacy, Undivided

Other news