HMO members know the drill. Got a sore throat? See your primary care physician (PCP). Need an allergy specialist? Ask your PCP for a referral. Having a cyst surgically removed? Make sure you get your health insurer's prior approval.

You understand if you don't follow your health plan's rules, your claims won't be covered. Sometimes even when you do everything right, your claim is still denied.

For example, you get your plan's permission for surgery. Months after the operation, you get a bill in the mail and discover your X-rays were read by a radiologist who doesn't participate in your health provider's network of doctors. X-ray claim denied.

Here’s another example. Your benefits handbook says your insurer fully covers diabetic test strips. When you go to pick them up, your pharmacist charges you the full price, saying your handbook — the only one you've ever been given — must be out of date. Claim denied.

What you can do to help prevent claims problems

When you have a group health plan through work, you're not responsible for negotiating your own health care contract. Even so, you should ask your employer plenty of questions about your group health plan. Here are five steps you can take to help minimize any "claims surprises" like those outlined above.

1. Never rely on what you think is true about benefits or providers covered under your plan — even if they are stated in your most recent benefits handbook. Always double-check with the plan on whether the benefits, services or providers you need are covered before you go to get treatment.

You can do this by calling your plan's customer-service department. Remember to take notes. Get the representative's name and write it down, along with the date, time and general details of your conversation.

If a claim problem arises and you need to file a grievance, these notes will come in handy. Most insurer's customer-service phone calls are tape recorded. Having the date and time of your call will make locating your call history with the representative much easier.

2. Should you have a problem with a claim, call the insurer and ask for an explanation. Again, remember to take detailed notes.

3. If the explanation is not consistent with your understanding of your health benefits, call or visit the person in your company responsible for benefits administration. Because of their position and their greater knowledge of the health plan details, they might be able to quickly resolve your problem.

4. If you have a claim problem that's unresolved, file a grievance with your health plan. If you get a denial, don't give up. In many states, the complaint eventually goes before a state sponsored grievance committee that's outside the plan (an "external review") or a "peer review committee" of other health care professionals. There's always a chance the denial might be reversed.

You might also want to complain to the officials who regulate your health plan. If your health plan is self-funded by your employer, it is regulated by the U.S. Department of Labor, which has regional offices.