Help With Problems
Where to Seek Assistance for Common Health Care Plan Problems |
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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 |
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 |
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 |
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You need claim forms |
Empire Plan – Agency HBA, United HealthCare for medical-surgical care, or Caremark for prescription drugs |
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 |
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 |
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. |