Health Advocates

Health Advocate Summary

Health Advocate Article

Health Advocate Q&A

Efficient and Dependable

The Personal Health Advocate (PHA) is a trained professional, typically a registered nurse, supported by medical directors and benefits and claims specialists, who understands the intricacies of the healthcare system and how to navigate through it. As soon as a member contacts us, they establish a relationship with a PHA who stays with them through to the resolution of the problem. Our PHAs 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 handle claims, benefits, grievances, paperwork and other issues. Health Advocate can be accessed 24/7. Our normal business hours are Monday–Friday between 8 am and 9 pm Eastern Time. After hours and during weekends, staff is available for assistance with issues that need to be addressed during non-business hours.

Health Advocate is always at your side

Clinical Support Services

Care Coordination

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 physicians
•Assisting members through complex medical conditions
•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
•Coordinating hospice and other services for terminally ill members
•Fostering communication and coordinating benefits between physicians and insurance companies

Advocates of Excellence

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 research
transportation and lodging when necessary.

Physician Locator

Helps members identify primary and specialist physicians, hospitals, dentists and related healthcare providers. Our first focus is on network relationships to help members use their
benefits to their best advantage.

Rx Advocate

The Personal Health Advocate can provide members with assistance on prescription drug issues including formulary and benefit questions.
•Helping members better understand multi-tiered pharmacy benefit plans
•Providing information for renewing prescriptions
•Providing information on generic drugs
•Locating lower-cost sources for prescription drugs that are not covered by their 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

Benefits Advantage

Personal Health Advocates help sort out and resolve 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 how we help include:
•Researching a member’s outstanding out-of-pocket responsibilities and resolving errors with providers and/or health plans
•Resolving eligibility problems and benefit and claim denials
•Uncovering charges incorrectly applied to the member’s deductible
•Resolving questions about whether services are condition-specific or related to preventive care
•Coordinating benefits between dental, medical and other healthcare providers
•Resolving incorrect plan procedure interpretations, such as emergency room claims
denied for a lack of pre-certification
•Assuring correct application of provider network status
•Uncovering errors in processing of “blind” network provider discounts
•Providing payers with additional information required to correctly pay a claim or apply a benefit
•Resolving coordination of benefits disputes between multiple carriers
•Satisfying plan requests for copies of referrals
•Resolving errors in the application of deductibles and co-payments

Health Cost Estimator (HCE)

HCE provides members with zip-code based cost estimates for common medical services and procedures. Personal Health Advocates provide members with personalized and easy-to-understand reports highlighting a range of comparative cost estimates for the
service in question, and will help answer any questions members may have.

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 identify duplicate or erroneous charges.

Appeals Advice

Our first approach is to resolve disputes and issues through discussion; however, when appropriate, 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, we can help the member formulate the argument, gather supporting documentation and write the letter of appeal to the health plan. In addition, and if appropriate, Health Advocate can telephonically represent a member during a hearing.

Coverage Advantage

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. PHAs can help with:
•Obtaining exceptions for a member to see providers outside of their capitated relationships,
if appropriate
•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 medical 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 alternative 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 get back to work
•Resolving eligibility questions involving disabled dependent rules, Family Medical Leave Act, COBRA, e

Healthcare Coaching

Personal Health Advocates provide members with the information necessary to help them become active participants in the management of their health. PHAs can assist with:
•Preparing members for visits with physicians and other providers
•Helping members better understand serious or chronic conditions
•Answering questions, and providing information and resources about medical terms, tests,
medications and treatments
•Locating the right doctor for a second opinion


Health Advocate helps locate and make arrangements for members’ special service 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 services we
can provide 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 help members and their families find the right physician for second opinion consultations. We can help arrange appointments and research questions about diagnoses, treatments and available support systems.
Complementary and Alternative Medicine Health Advocate helps 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 TM

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

Healthy Wheels

Health Advocate helps research transportation services to support our members’ healthcare needs.

Senior Care Navigator

For employees or family members approaching retirement or who are 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. We have helped seniors with:
•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


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

Health Advocate, Inc., the nation’s leading independent healthcare advocacy and assistance company, serves more than 7,000clients including the nation’s leading companies —providing more than 20 million Americans with expert, personalized help to resolve

healthcare and insurance-related issues. The company offers a spectrum of add-on time- and money-saving solutions designed forboth employers and employees.

Core Health Advocacy

•Personal Health Advocates handle a rangeof clinical and healthcare insurance issues
• Interacts with providers and insurance
• Gets the right answers at the right time
•Complementary Solutions
•Wellness Advocate™
•Chronic Care Management™
•Benefits Gateway™/Health Information Dashboard™
•Medical Bill Saver™
•Tobacco Cessation™
•MedChoice Support™
• FMLA Support™
•Independent Appeals Administration™
•Enrollment Advocate™
•External Appeals Administration™