Carol McDaid
Winning strategies for filing a mental health insurance coverage grievance
CFYM Note: This is the last in the series by Carol McDaid on your rights with regards to mental health insurance parity laws and expanded coverage under the Affordable Care Act. Tuesday’s post provided an overview of what types of denials to look out for. Today, Ms. McDaid tells readers how to file a grievance for denial of mental health insurance coverage.
When should I file an appeal
Mental Health America compiled this list of questions to help you understand if you should appeal a coverage denial. At first glance, the questions may seem to require a sophisticated understanding of your plan and the law, but you can simplify it this way: If the answer is YES to any of the following questions, the plan is most likely not in compliance with the new laws.
- Are there separate or higher deductibles for mental health and/or substance use treatment than for most medical/surgical care?
- Are the plan’s co-payment requirements for mental health and substance use treatment higher than those for most medical/surgical benefits?
- Are the co-pays for medications used to treat mental health and substance use conditions higher than the co-pays for most medications used to treat other conditions?
- Is there a higher co-insurance ratefor mental health and/or substance use treatment than is required for most medical and surgical care?
- Does the plan set a higher out-of-pocket maximum or limit for mental health and/or substance use disorder treatment beyond which more comprehensive coverage applies?
- Does the plan impose more restrictive limits on how often treatment for mental health and/or substance use treatment will be covered compared to treatment for medical and surgical care?
- Does the plan set a lower limit on the number ofvisits allowed for mental health and/or substance use treatment compared to the number of visits covered for most medical or surgical care?
- Does the plan place a lower limit on the number of days covered for mental health and/or substance use treatment than are covered for most medical and surgical care?
- Does the plan cover out-of-network medical or surgical care but notout-of-network mental health and substance use disorder treatment?
- Does the plan apply higher financial requirements or stricter treatment limitations for out-of-network mental health or substance use disorder care than apply to most out-of-network medical and surgical benefits?
Know your rights
If coverage is denied, first know that it is not the end of the story. Challenging a coverage denial by a health plan is a legal right guaranteed to all insured people. All plans, including Medicaid managed care, private individual and group insurance policies, and employer-sponsored health plans must provide a process to appeal a denial. If you are in a medical crisis or have an urgent need, you might even be eligible for an expedited review and response of 1 to 3 days.
Under the mental health parity law, plans are now required to provide a reason for the denial of any claim and provide the medical necessity criteria upon request. This should improve the appeals process, or at least make the denial more transparent.
Engage your provider
Once denied, you should enlist your provider’s help. Your provider will likely be motivated to aid you in your appeal, as providers may be held legally liable for negligence if they do not appeal and you or someone else is hurt as a result. To begin, your provider can request written notification of the reasons for denial on your behalf.
Remember, though, that while your provider may help you in your fight, you are your strongest advocate. Some people step back from the appeals process once a provider becomes involved. Do not assume a provider will have the time or dedication to see an appeals process through the way you will. Your provider is vital to your appeal, and may even be the one to file the appeal; but you must be the one who manages and tracks the details and progress.
Don’t give up
Appealing denied benefits can be time consuming and laborious, but we can’t let the process prevent us from seeking our benefits. It once took me three years to obtain reimbursement for denied service, but I got it. Know that there are resources, including the Parity Implementation Coalition, to help guide you; and understand that thanks to the parity and health reform laws, the onus is now on the insurer.
Your turn
We want to hear about your experience.
Have you ever appealed a health insurance denial for mental health coverage?
Did you solicit help from others in filing your appeal?
What piece of advice would you offer someone appealing a denial?
Connect With Us