Danya Institute Inc.

What You Should Know About Seeing Your Doctor

What You Should Know About  Seeing Your Doctor

Most health plans give you the best deal on services when you see a doctor who has a contract with your health plan. While you may be able to see doctors who don’t contract with your plan, visiting an “in network” provider usually means you will have lower out of pocket cost.

Does my new insurance plan cover my doctor?

To find out if your doctors and other health care providers are covered through your new Marketplace plan
or to find a covered provider if you don’t have one yet:
1. Visit your health plan’s website and check their provider directory, which is a list of the doctors, hospitals, and other health care providers that your plan contracts with to provide care.
2. See your health plan’s provider directory on HealthCare.gov, in “See Plans Before I Apply.”
3. Call your insurer to ask about specific providers. This number is on your insurance card, the insurer’s website, and HealthCare.gov.
4. Call your doctor’s office. They can tell you if they accept your health plan.
5. Call the Marketplace Call Center (1-800-318-2596) where a trained representative can help you find your insurer’s number.

Is there an appeals process if I go to my regular doctor and find out later that my new plan doesn’t cover them?
Yes. If your health insurance company doesn’t pay for a visit to the doctor, you have the right to appeal the decision and have it reviewed by an independent third party. To learn more about the appeals process, read “Appeals: eligibility and health plan decisions in the Health Insurance Marketplace.”

Your insurance company must first notify you in writing within a set amount of time (based on the type of claim you filed) to explain why coverage was denied. They also have to let you know how you can appeal their decisions.

If the timeline for the standard appeal process would seriously put your life at risk, or risk your ability to fully function, you also can file an appeal that would get you a quicker decision. If you meet the standards for an expedited external review, the final decision about your appeal must come as quickly as your medical condition requires, and no later than 72 hours after your request for external review is received.


If you have additional questions, call the Marketplace Call Center at 1-800-318-2596. TTY users should call


This information can be found be going to: http://marketplace.cms.gov/getofficialresources/publications-and-articles/seeing-your-doctor.pdf