Know Your Rights

When your medical claim is denied

If your medical claim was denied by Medicare and you would like to appeal it, you should contact Medicare and follow its appeal procedures. If the claim was approved by Medicare, but the balance was denied in whole or in part for any reason by HealthChoice, either you or your authorized representative can request that the claim be reviewed by calling Customer Care or by submitting a written request to the HealthChoice Appeals Unit within 180 days of your receipt of a denial.

Medicare Part D prior authorization and appeals

When your pharmacy claims is denied, you can appeal. There is a review process that is required for coverage of certain drugs such as those that:

• Are high cost.
• Have specific prescribing guidelines.
• Are generally used for cosmetic purposes.
• Are limited in quantities.

Oklahoma privacy laws and the federal Health Insurance Portability and Accountability Act of 1996 protect the privacy of an individual’s health information. For HIPAA purposes, OMES has designated itself as a hybrid entity. This means that HIPAA only applies to areas of OMES operations involving health care, and not to all lines of service offered by OMES. 

The Medicare Beneficiary Ombudsman helps you with complaints, grievances and information requests about Medicare. The Medicare Beneficiary Ombudsman makes sure information is available about:

• What you need to know to make health care decisions that are right for you.
• Your Medicare rights and protections.
• How you can get issues resolved.

HealthChoice is licensed by the Oklahoma Insurance Commission to provide utilization review services. Our Utilization Review Plan is updated on an annual basis to reflect changes in policies and procedures.