Health Advocate

Information below is from Health Advocate.


The Personal Health Advocate is a trained professional, typically a Registered Nurse, who understands the intricacies of the healthcare system and how to navigate through it. As soon as a member contacts us he/she establishes a relationship with a Personal Health Advocate who stays with them through to the resolution of the problem. Our Personal Health Advocates demonstrate a commitment to service excellence, have strong problem solving skills and support members as they seek healthcare services and interact with providers and insurers. Personal Health Advocates work in tandem with Medical Directors and with our team of administrative experts who handle claims, benefits, grievances and paperwork issues.

Health Advocate is available 24 hours a day, 7 days a week using a toll free phone number. Regular hours extend from 8 AM to 6 PM weekdays. After-hours calls are handled by the Personal Health Advocate on call.


The Personal Health Advocate helps members coordinate care among physicians and medical institutions in various ways:

  • Helping members understand tests, treatments and medications recommended or prescribed by their physician.
  • Assisting members through a complex medical condition.
  • Facilitating the transfer of medical records, x-rays and lab results prior to a scheduled appointment with a new physician.
  • Arranging for home-care equipment following discharge from the hospital.
  • Facilitating a review of test results with another physician for confirmation of a diagnosis.
  • Coordinating and making arrangements for diagnostic tests.
  • Coordinating care for a member with complicated medical issues.
  • Consolidating a multiple-day testing schedule for special needs members.
  • Arranging for a member to be evaluated for participation in a clinical trial.
  • Arranging hospice and other services for terminally ill patients.
  • Facilitating transfer from a community hospital to a tertiary care facility.
  • Fostering communication and coordinating benefits between physicians and with insurance companies.


Helps members with rare, serious or complex medical conditions identify top medical institutions, critical illness providers and specialized medical programs across the country. Our Personal Health Advocates will schedule appointments and coordinate transportation and lodging when necessary.


Claims Assistance: Personal Health Advocates help sort out and solve claims and related paperwork problems. We work on coverage issues and help members understand the coding and payment rules that apply to their circumstances. Examples of other services include:

  • Researching a member’s outstanding out-of-pocket responsibilities and resolving errors with providers and/or their health plan.
  • Correcting balance-billing problems.
  • Resolving eligibility problems and benefit and claim denials.
  • Correcting charges incorrectly applied to the member’s deductible.
  • Resolving questions over whether services are condition specific or related to preventive care.
  • Coordinating benefits between dental, medical, workers comp and disability carriers.
  • Resolving incorrect plan procedure interpretations such as emergency room claims denied for a lack of precertification.
  • Assuring correct application of provider network status.
  • Correcting errors in processing of “blind” network provider discounts.
  • Providing payers with additional information required to correctly pay a claim or apply a benefit.
  • Resolve coordination of benefits disputes between multiple carriers.
  • Satisfying plan requests for copies of referrals.
  • Resolving errors in the application of deductibles and co-payments.
  • Providing the correct member insurance information to providers.


Fee Negotiation: When necessary, Health Advocate can attempt to negotiate fees with healthcare providers to lower the member’s out-of-pocket costs. This is often done prior to the member receiving services. We can also review questionable bills to catch duplicate or erroneous charges.

Grievance Advice: Our first approach is to resolve disputes and issues through discussion; however, when necessary we will provide advice or assistance to members when filing a complaint or grievance with their health insurer or health plan administrator. We can provide the member with guidance regarding their appeal rights and when all other means have failed and we agree that the issues are valid, help the member formulate the argument, gather supporting documentation and write the letter of appeal to the health plan.


If there are questions of coverage for a particular service, or if coverage for clinical care has been denied, the Personal Health Advocate can help members through the review and appeals process. We can also assist in identifying alternative coverage options when necessary.

  • Obtaining exceptions for a member to see providers outside of their captivated relationships.
  • Obtaining referrals for required services.
  • Locating in-network suppliers and obtaining plan approval for the use of out of network suppliers for necessary healthcare equipment and supplies that are not available from in-network suppliers.
  • Obtaining transitional care coverage at an in-network benefit level when medically necessary.
  • Resolving questions of denial of benefits deemed to be non-covered, not medically necessary or ineligible.
  • Counseling members regarding current benefit costs and the cost of alternatives approaches.
  • Helping members understand the process for obtaining coverage for medical equipment, devices, supplies. (e.g., hearing aids, diabetic supplies, compression stockings)
  • Answering coverage questions.
  • Providing information regarding benefit level coverage comparisons for various providers.
  • Transitioning members from out of network to in-network providers.
  • Assisting members with the preauthorization and predetermination process.
  • Locating “hard-to-find” IV drugs or home care services to facilitate hospital discharge.
  • Assisting employees with disability coverage questions and helping them back to work.
  • Resolving eligibility questions involving disabled dependent rules, Family Medical Leave Act, COBRA, etc.


The Personal Health Advocate can provide members with assistance on prescription drug issues including formulary and benefit questions.

  • Providing information for renewing prescriptions.
  • Providing information on generic drugs.
  • Locating lower cost sources for prescription drugs that are not covered by the health plan.
  • Assisting members in obtaining mail order prescriptions.
  • Resolving questions between members and pharmacies regarding the amount of product requested and the amount dispensed.
  • Obtaining coverage for medications that require mail order.


Helps locate and makes arrangements for members’ special services needs. The individual member is responsible for payment of any specific services arranged on a fee-for-service basis that are not covered by an insurance plan. Examples of the kind of services we can help members with include:

  • Locating homemaker, adult day care and rehabilitation services not covered by the member’s health plan.
  • Locating inpatient private duty nursing.
  • Finding a group home for individuals with special needs.
  • Locating home health aides.
  • Helping members complete qualification applications for individual coverage options, including Medicaid and Medicare.


M.D. Direct™: In the case of serious medical illness, Health Advocate can provide members with access to experts for consultations and second opinions. Every step is taken so that members and their families are advised in full as to the diagnosis, treatment, medications and support systems available to them.

Complementary and Alternative Medicine: Health Advocate helps to identify and coordinate a range of wellness services including those offered by Complementary and Alternative Medicine (CAM) practitioners in areas such as acupuncture, chiropractic care and massage therapy.

Mind Matters™: If necessary, Health Advocate can help members find an appropriate mental health provider to meet their specific needs.

Appeals Representation: When all other means of dispute resolution have failed and we believe that the member’s position is valid, Health Advocate will represent members during the appeals process including attending health plan hearings. (Representation at appeals hearings will be billed at an hourly rate, plus travel expenses, if any.)

Healthy Wheels™: Health Advocate helps arrange transportation services to support our members’ healthcare needs.

Senior Care Navigator: For employees or family members approaching retirement or already retired, we offer access to a wide array of services specifically geared for seniors. Our Personal Health Advocates understand senior members’ needs and can help members select the appropriate professionals. Among the kind of issues we have worked on are:

  • Locating alternative care facilities.
  • Obtaining coverage for medical supplies.
  • Providing information on adult day care programs.
  • Coordinating coverage for home care services with Medicare and Medicaid.
  • Assisting with the transition of insurance coverage and benefits from private insurance to Medicare.
  • Locating physicians who make house calls for people who cannot easily get to the doctor’s office.


Wellness Advantage™: For those members looking for a personalized approach to weight management, getting and staying in shape, stress management, Health Advocate can help locate providers and arrange appointments for these services.


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