Why Calls to Your Health Plan Customer Service Are So Frustrating — and What to Do About It
Author: Samantha Bridge, RN, MSN, MBA-HCM, IQCER
Date: April 15, 2025
Why Calls to Your Health Plan Customer Service Are So Frustrating — and What to Do About It
If you’ve ever spent an hour on hold with your health insurance company only to hang up feeling more confused than when you called, you’re not alone. Calling your health plan’s customer service department can be one of the most frustrating parts of navigating healthcare—especially when you’re trying to understand a denial, appeal a prior authorization, or resolve a billing issue.
Unfortunately, there are structural reasons why these calls often lead nowhere. Here’s what you need to know about why calling doesn’t always get results and, more importantly, what you can do instead.
The Reality Behind Insurance Customer Service Calls
1. Long Wait Times and Call Transfers Are the Norm
Customer service teams are often understaffed, especially during high-volume periods like the start of the year or open enrollment. It's not uncommon to be transferred multiple times, or wait upwards of 30–60 minutes just to speak with someone.
2. Representatives Often Don’t Have Full Access to Decision-Makers
Most health plan customer service agents are limited to surface-level information. They typically do not have access to your full case file, the clinical reviewers, or the individuals actually making the decision on your claim or appeal. They can read notes, but they cannot investigate further and often lack the knowledge to explain barriers in great detail.
3. They’re Not Required to Give You Detailed Explanations
Neither federal law nor most state laws require insurers to fully explain complex denials or authorization decisions over the phone. The details of how a decision was made—including medical necessity reviews—are not always visible to call agents.
4. Verbal Appeals and Grievances May Not Be Valid
Under federal law, there is no requirement that verbal appeals or grievances be accepted or processed for commercial insurance plans. Some states do permit verbal submissions, but this varies widely.
States that permit verbal appeals or grievances include:
• California (CA Health & Safety Code §1364.35)
• New York (11 NYCRR 410.9)
• Illinois (50 Ill. Adm. Code 4520.40)
• Texas (28 TAC §19.1810)
But even in these states, verbal submissions may only apply to certain types of grievances—and you should always follow up in writing.
What You Can Do Instead (And Why It Works)
1. File Your Appeal or Grievance in Writing
A written appeal triggers a formal review process under both state and federal regulations. Health plans are required to:
- •Respond within a specified time frame (usually 30–60 days)
- •Document their rationale
- •Provide review by a qualified individual (e.g., a medical director or specialist)
2. Request Your Denial File Before Appealing
You have the right to request your full denial file, including:
- •Medical reviews
- •Notes from internal reviewers
- •Clinical policy bulletins
According to ERISA and NCQA standards, this information must be provided in writing upon request. Health plans are not required to share these details over the phone.
3. Submit Missing Information Yourself
Denials are often issued due to missing or incomplete information. You can strengthen your case by submitting:
- •Physician letters
- •Medical records
- •Lab results or imaging
- •Statements showing medical necessity
4. If Your First Appeal Is Denied, Don’t Stop There
Many plans offer a second-level appeal, which is required to be reviewed by different decision-makers for a full and fair review. You may also be entitled to an external review by an independent organization—especially for services deemed not medically necessary.
5. Ask for Exception Requests
If a treatment is denied due to being out of network, non-formulary, or not typically covered, you can file an exception request. These must be evaluated under both federal and state rules, depending on your plan type.
Why Written Complaints and Appeals Get Results
- •They trigger an official review. Telephone complaints often do not.
- •They create a paper trail. This is vital if you need to escalate to your state’s insurance department or a legal advocate.
- •They are required by law to be addressed. Your health plan is legally obligated to respond to formal appeals and grievances in writing—often within strict timeframes.
Final Thought: Know the Rules of the Plan You Signed Up For
Every health plan is technically a contract, and the way you can access information—and appeal decisions—is determined by that contract. This includes:
- •How to request prior authorization
- •Where to send an appeal
- •Whether verbal requests are honored
You may not like the structure, but once you're enrolled, your rights are largely determined by that plan document.
Need Help Navigating the Process?
At EZ Med Appeal, we help people understand why they were denied, request the right records, and submit powerful written appeals and grievances. If you’re not sure what to do next, we’re here to help you take the next step—confidently.
Click here to see how we can help.
Sources & References:
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