Trying to find care for behavioral health issues can seem like a never-ending battle once you have found access to care. Being denied that care is overwhelming and can leave one feeling hopeless. Is there something you can do if your insurance company denies care? There is. We will help you understand your options and outline some steps you can take with your insurance company, including filing an appeal. An appeal is a request for your health insurance company to review a decision that denies a benefit or payment. 

Don’t get discouraged! We know this can be overwhelming, but insurance companies overturn denials through appeals. It is never guaranteed that they will, but getting the appropriate care is worth the time. 

Step 1. Understand your plan

  • Review your plan and determine what type of plan you have
    • Employer-sponsored is the most common way Americans receive insurance coverage. Employer-sponsored is any health insurance plan that you receive through your employer 
    • Individual health insurance is coverage that you purchase on your own as opposed to obtaining it through an employer
    • Government plans, like Medicaid, are plans that are provided to the consumer through the federal and state governments and include eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities
    • Medicare is a federal health insurance program for people who are 65 and older and younger people with disabilities and end-stage renal disease

Step 2. Organize your materials

  • Understanding what materials you must have on hand and keep can help make the process easier. Keep all copies related to your claim and denial. This includes:
    • EOB or Explanation of Benefits – You should receive an explanation of benefits for all services approved or denied.  
    • Any letters showing what services were denied
    • Any documentation you send to the insurance company
    • If you can, obtain copies of any documentation your doctor sent to the insurance company requesting the needed care
    • A copy of any appeal documentation completed by you or the doctor, especially any you are required to sign
    • Document, document, document! We can’t stress this enough. Keep a journal of every phone conversation with your insurance company or doctor related to your appeal or denied care. Include the date, time, name, and title of the person you talked to and details about the conversation. Save any emails and/or voicemails. The more documentation you have, the better. This will be especially helpful if the insurance company does not have a record of a conversation.
    • Make copies! You may send documentation to the insurance company or doctor; always ensure you have a copy. Keeping your original documents and submitting copies to the insurance company is best.  You will need to send your insurance company the original request for an internal appeal and your request to have a third party (such as your doctor) file an internal appeal for you.  Make sure you keep copies of all documents for your records.

      *In an internal appeal, the insurance company takes a second look at the claim by representatives who were not involved in the original decision. An external appeal is when a neutral third party independently reviews the documents.

Step 3. Communicate with your provider and request a letter outlining the medical reasons for the requested treatment or service. This may be helpful in an appeal or if you have to file a formal complaint (we will look at this in another section). 

Step 4. File an appeal

*It is important to note that some plans are exempt from the Federal Parity Law. These include Medicare, Tricare, and local and state self-funded government plans that may apply for an exemption from the Centers for Medicare and Medicaid Services (CMS). To learn more about parity, please visit our page on insurance parity at https://thejemfoundation.com/insurance-parity/

  • Sometimes, a claim can be denied due to a clerical error. Check over the documentation from your insurance company and check for errors. If you find one, ask the insurance company to correct it before you proceed. If it was an error from your medical provider, ask them to correct the problem and resubmit the claim.
  • Contact the insurance company if it is not due to a simple error. Make sure you have your documentation in front of you before you call. Have your EOB, dates of service, diagnosis, and any notes from conversations with your doctor. Ask them why you were denied and let them know you wish to file an appeal. Remember to put this down in your journal!
  • Understand the time you have to submit an appeal. You have six months after you learned that your claim was denied to appeal. 
  • File an internal appeal. The insurance company should have sent you instructions for filing an appeal along with a rejection letter. If you don’t have one, contact the insurance company and tell them you need an appeal form.  
  • Fill out the appeal form. Many insurance companies want you to use their appeal form. 
  • Contact your doctor, let them know you are filing an appeal. Ask you doctor to write a letter outlining the need for care. Your doctor may also be able to help you with your appeal paperwork, so ask them. Not all will be able to, but it doesn’t hurt to ask.
  • Some states have a Consumer Assistance Program that can help you with your appeal. Unfortunately AZ is not one of those states. 
  • Submit your appeal in a timely manner. You should receive a response within 60-90 days

*Be sure to communicate with your doctor. If there is a bill due for the needed care, they may need payment while you wait for the decision from the insurance company. 

Step 5. If your internal appeal is denied request an external appeal

  • Contact your insurance company and let them know you want an external review
  • Submit a written request for external review within 60 days of the date you received the insurance company’s decision Or, ask a doctor or other medical professional to request the review for you by filling out an Appointment of Representative form. This form allows someone to file a complaint or appeal for you.
  • If the external review rules in your favor, the insurance company will have to pay the claim. However, the reviewer may rule in favor of the insurance company. 

Step 6. Contact your state agencies and report the problem

  • If the insurance company or health plan fails to respond in a timely fashion, or if they inappropriately deny care despite your appeal, you can file a complaint with your state Department of Insurance. Find the complaint form for AZ here.
  • If you are outside of AZ you can find state agency resources by visiting https://www.parityregistry.org/resources/

After filing a complaint with your state agency would you also consider filing one on paritytrack.org? Parity Track is a website dedicated to ending behavioral health discrimination. You can file a complaint by visiting https://www.parityregistry.org/complaint/

For more resources visit: https://www.paritytrack.org/