Factsheet: What can I do if my insurance company is refusing to approve claims for mental health treatment?
What can I do if my insurance company is refusing to approve claims for mental health treatment?
If you are facing a situation where your insurance company is refusing to pay for treatment, there are a number of active steps you can take and options that may be available to you. In dealing with your insurance company regarding treatment denials there are several important things to keep in mind that may increase the likelihood that you will eventually succeed in getting treatment covered:
- Know the facts
- Keep good records
- Be factual, thorough, and persistent
- Enlist outside help, if needed
Know the Facts about Your Insurance Coverage and State Parity Laws
- Review your insurance policy to see what is covered and any steps you must take for treatment to be approved before starting treatment, if possible. Contact your insurance company to review what mental health services are covered and the policies that govern access to treatment. See Mental Health America’s FAQ “What do I need to know about my insurance benefits when seeking treatment?” for a list of questions to ask to help you understand your benefits.
- If you have trouble understanding the policy, see if someone from your doctor’s office, your employer, or a trusted friend, can help explain the information.
- Learn about your state’s parity laws. See Mental Health America’s FAQ “What do I need to know about my state’s mental health parity laws when seeking treatment?” for information and resources to help you understand legal protections available within your state.
Understand Your Insurance Company’s Appeals Process
- Find out about your company’s appeals process including how many times you can appeal, deadlines, types of documentation required, and if external appeals are available in your state. There are specific steps to make written appeals and legal timelines for the insurance company to notify you of its decision.
- Ask whether the insurance company has an Insurance Ombudsman who helps in situations where there is a disagreement between the company and patients/consumers. If you have a problem getting this information directly from your insurance company, contact the consumer hotline at your state Insurance Department http://www.naic.org/state_web_map.htm or state Insurance Commissioner’s office http://www.naic.org/documents/consumer_hipaareps.pdf to request this information. In some states, your local or state Mental Health America affiliate may also be able to provide this information or help connect you with the Insurance Ombudsman. To find the affiliate(s) in your state, use our MHA Affiliate Locator http://www.mentalhealthamerica.net/go/searchMHA.
- Find out if your state has a requirement that your claim be reviewed by an external appeal organization if you have exhausted appeal procedures with your insurance company. If so, you may be able to pursue additional review of your treatment decision. The following chart provides detailed state-specific information about external appeals http://www.kff.org/consumerguide/states.cfm.
Steps to Take if You Receive a Treatment Denial: General Guidelines
- If treatment is denied, appeal the decision by phone and in writing immediately.
Copy a lawyer on your letters. Sometimes a simple letter from a lawyer will encourage action.
- Keep a record of all communications with your insurance company and other organizations including dates, times, names of individuals you spoke with, and all correspondence you’ve received.
- Obtain a written definition of medical necessity from the insurance company since this is a common basis for deciding whether to approve treatment.
- Seek your doctor’s help in filing an appeal. If your provider recommends a course of treatment, she/he is ethically bound to appeal on your behalf. Your insurance company may require that you complete written paperwork that clearly explains why the treatment is medically necessary. If possible include a description of the potential harm that will be done if the treatment is not approved.
- Let the insurance company know that you will also contact the insurance commission, employer, and media to obtain assistance.
- Contact your Insurance Commissioner. When you contact the Insurance Commissioner’s Office, make sure to ask if your state offers the opportunity to have your claim be reviewed by an external organization, if all levels of appeal directly with the insurance company have been unsuccessful.
For more detailed information on appealing treatment denials, we recommend you review the following resources:
Mental Health America’s guides “Consumer’s Checklist: How To Overturn Managed Care Treatment Denials” www.mentalhealthamerica.net/go/faqs/overturn-treatment-denials and “The Consumer’s Right To Health Care: How To Overturn Managed Care Treatment Denials” http://mentalhealthamerica.net/go/help/how-to-pay-for-treatment/dealing-with-treatment-denials
The Center for Consumer Health Choices, Consumers Union guidebook “A Consumer Guide to Handling Disputes with your Employer or Private Health Plan” http://www.kff.org/consumerguide/7350.cfm offers detailed information on appealing treatment denials.
National Association of Anorexia Nervosa and Associated Disorders guidelines on coping with difficulties in insurance coverage for treatment of eating disorders http://www.anad.org/22553/103522.html. Many of the suggestions in this document may be helpful in appealing treatment denials, in general, not only insurance company denials of treatment for eating disorders.
National Eating Disorders Association’s section on dealing with insurance and appealing treatment denials http://www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/InsuranceIssues.pdf
Other Resources
Since state laws governing insurance regulation and consumer protections differ, we suggest contacting the following organizations if you need further assistance. They can help you better understand the laws and regulations in your state that might help you get an unfavorable decision overturned.
Your state Insurance Department http://www.naic.org/state_web_map.htm or state Insurance Commissioner’s consumer hotline http://www.naic.org/documents/consumer_hipaareps.pdf can answer questions about your insurance, check to be sure your insurance company is following mental health parity laws in your state (laws that guarantee equal coverage for mental health conditions as for other physical illnesses), and may be able to help you deal with your insurance company if you are having a problem.
The Protection & Advocacy (P&A) organization in your state. To find the P&A, use the Mental Health Services Locator at http://mentalhealth.samhsa.gov/databases. Once you’ve selected your state, use the State Resource Guide option to find your P&A office.
Your Mental Health America state or local affiliate http://mentalhealthamerica.net/go/searchMHA. Your MHA affiliate may be able to: help connect you with your insurance company ombudsman; advocate directly on your behalf or connect you with an advocacy organization within your state; or assist you in finding affordable alternative treatment options.
Local legal aid clinics may be able to help if you think your treatment denial may violate state law regarding consumer confidentiality, parity, or consumer rights. To find the Legal Aid office serving your area, visit www.lsc.gov.
Your state and/or federal lawmaker. These individuals need to hear directly from their constituents about their experience in trying to access treatment and services. To find contact information for the political officials who represent your area, visit http://takeaction.mentalhealthamerica.net/site/PageServer?pagename=Find_Your_Legislators.
For More Information:
For help finding treatment, support groups, medication information, help paying for your medications, your local Mental Health America affiliate, and other mental health-related services in your community, please click here to access our Frequently Asked Questions and Answers. If you or someone you know is in crisis now, seek help immediately. Call 1-800-273-TALK (8255) to reach a 24 hour crisis center or dial 911 for immediate assistance.
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