Help With Problems

Where to Seek Assistance for Common Health Care Plan Problems

Problems

1st Contact

PEF Joint Committee on Health Benefits

You haven’t received or have lost your identification (ID) card(s)

Empire Plan – Agency HBA who is usually located in the Personnel Office
HMO – HMO should be contacted directly
Dental – EmblemHealth should be contacted directly Vision – Davis Vision should be contacted directly

Health Benefits can help if you haven’t been able to get ID card after contacting your HBA or health care plan

PEF Health Benefits: 1-800-342-4306 or 518-785-1900 x283

You need informational materials such as the NYSHIP General Information Book or Empire, Dental, or Vision Plan booklets

Agency HBA

Health Benefits can help if you are unable to get informational materials from your HBA

PEF Health Benefits: 1-800-342-4306 or 518-785-1900 x283

You need claim forms

Empire Plan – Agency HBA, United HealthCare for medical-surgical care, or Caremark for prescription drugs
Dental – Agency HBA or EmblemHealth
Vision – Davis Vision HCSA/DCAA – Flex Spending Acct

Health Benefits can help if you are unable to get claim forms from your HBA or insurer/administrator

PEF Health Benefits: 1-800-342-4306 or 518-785-1900 x283

You or a covered dependent is denied benefits because you or s/he is not enrolled in the Plan or was ineligible at the time of service

Your agency HBA is responsible for ensuring your enrollment records are accurate and making any necessary corrections

Health Benefits can help if your HBA has been unable to resolve problem

PEF Health Benefits: 1-800-342-4306 or 518-785-1900 x283

You need to determine if a service or item is covered by your plan

Empire Plan – appropriate insurer or administrator should be contacted directly
HMO – HMO should be contacted directly
Dental – EmblemHealth should be contacted directly
Vision – Davis Vision should be contacted directly

Health Benefits can help if you are unable to get information from the appropriate source

PEF Health Benefits: 1-800-342-4306 or 518-785-1900 x283

You disagree with a benefit determination made by the insurer, administrator, or HMO, e.g., denial of benefits or the amount paid

Contact appropriate insurer, administrator, or HMO directly for an explanation. If you disagree, file an appeal. Contact your HBA if you need help with the appeal process. Be sure to keep copies of correspondence and document phone calls

Health Benefits can help if you are dissatisfied with outcome of your appeal. Send pertinent documents including chronology of what has happened up to this point and copies of all correspondence sent to and received from the carrier, administrator, or HMO

PEF Health Benefits: 1-800-342-4306 or 518-785-1900 x283

You are dissatisfied with any aspect of the health benefits provided to you

PEF Health Benefits

Health Benefits will document and/or investigate your complaint

PEF Health Benefits: 1-800-342-4306 or 518-785-1900 x283

Additional Resources

Quackwatch
is an independently operated site containing useful information about health fraud and quackery.

NYS Department of Financial Services Health Insurance Resource Center includes How to File a Complaint, External Appeal information and health related insurance laws.

NYS Education Department, Office of the Professions includes plain-language consumer information about professionals licensed by the Education Department, e.g., chiropractors, dentists, nurses, physical and occupational therapists, optometrists, psychologists and social workers. Also included are a professional discipline complaint form and information about professionals disciplined by the Board of Regents.

Federal Trade Commission, Bureau of Consumer Protection website called Complaint Assistant explains why it’s important to submit complaints and how your personal information is protected. Information available in Spanish.