Appealing a denial of care by a private insurance company

The Denial Notice

You should get a denial notice telling you why the insurance company will not authorize or pay for the services requested by your doctor or therapist. The notice should give you enough detail so you know why the insurer thinks the services are not medically necessary for you.

A denial occurs when the insurer:

• Denies your provider’s request for services,
• Changes your provider’s request for services (for example: giving fewer sessions over the same time period, or the same number of sessions over a shorter time period),
• Ends your current service approval.

The denial notice must:

• Identify specific information on which the denial is based,
• Discuss your medical condition, diagnosis, treatment, and specific reasons why the medical evidence fails to meet the insurer's medical review criteria,
• Specify any alternative treatment option offered, if any
• Refer to and include the clinical practice guidelines and review criteria used in making the decision to deny care coverage.

Once you have the denial notice, file an appeal with the insurance company immediately. Send it in writing and be sure to include:

• Your full name and policy number,
• Exact name of the service your provider requested
• Over what time period the service was requested (for example, from November 15, 2008 through March 14, 2009),
• Whether you would like the service you are receiving to continue while the decision is being appealed,
• Reasons you think the insurance company should change its decision,
• If you know your provider will be sending them a letter about why the service is medically necessary, say so in the appeal.

You usually can keep receiving services that were initially authorized by the insurer (for example, if you were getting therapy twice a week for three months, that will continue until the insurer issues its final decision). Ask for the services to continue until the appeal is decided.

It is better to do the appeal in writing and keep a copy of the appeal for yourself.

Each individual plan has a different appeals process. Information on appeals is usually published in the member benefit handbook, which your plan is required to provide you with. Call the plan's customer service number to request a handbook if you do not have one.

How long will my appeal take?

A private insurance company must decide within 30 business days of when it received your appeal. If you are in-patient, the decision must be made prior to your discharge. You also can request an expedited appeal process (a decision within 48 hours) if your doctor is willing to certify that there is substantial risk of immediate harm if services are discontinued. You usually can keep receiving services that were initially authorized by the insurer. For example, if you were getting therapy twice a week for three months, that will continue until the insurer issues its final decision.

Supporting your claim for services with a letter from your clinician

Ask your doctor or therapist to give the insurer a letter that supports your appeal as soon as you get the denial. The letter may be short, but it should provide information that specifically addresses the reasons given for the denial in the notice the insurer sent you. If possible, the provider also should give the insurance company medical records supporting the care requested.

You do NOT need to file the letter from your clinician with the appeal, so do not wait to appeal!

Insurance company documents you should consult to decide how to support your claim

There are several documents you should look at when deciding how to show the insurance company that the services should be paid for:

• Your health insurance policy
  Consult your explanation of benefits handbook to make sure the services you want are covered. The insurer is required to provide you with a copy, so call them if you no longer have one.Insurance companies usually will not pay for educational services or housing. However, if there is a medical piece or aspect to the educational services or housing arrangements, the insurance company should pay for the therapy or other medical portion.
• Your insurance company's protocols and criteria for covered services
  Insurance companies often use "grids" or "checklists" to determine when to pay for a service and when to deny coverage. Sometimes these grids look at the diagnosis; other times they look at how severe the symptoms are. Your provider may have to get these protocols for you - they may be included in the provider manual of the insurance company. Ask your therapist or doctor to use the language in these protocols to request services and to appeal service denials.

Some links to insurance company criteria:

• Harvard Pilgrim Healthcare (managed by United Behavioral Health) 
  • Clinical and Medical Necessity Decision Criteria
  • Policy regarding Diagnosis, Treatment, and Referral for Behavioral Health Disorders
  • Policy regarding the use of Psychopharmacological Medication
  • Policy regarding Co-existing Medical and Behavioral Health Disorders
• Blue Cross Blue Shield Massachusetts
  • Behavioral Health Policy: Outpatient Psychotherapy
  • Definition of medical necessity (scroll down to M), which is used in determining coverage for inpatient psychotherapy
• Fallon Community Health Plan (managed by Beacon Health Strategies)
  • The medical necessity criteria used to make authorization decisions available only to registered members on the Beacon Health Strategies site or by calling Beacon’s member service department at 1-888-421-8861
• Neighborhood Health Plan (also managed by Beacon Health Strategies)
  • Provider Behavioral Healthcare Manual
  • Provider Prior Authorization Grid
  • Many insurers only disclose their criteria to providers in their network. Some plans only provide the person it insures with their criteria when it is used to deny services to that person. It would be wise to ask your clinician to provide you a copy of these criteria.

Mental Health Parity

The insurance company must provide all medically necessary services for certain biologically based diagnoses. They also must provide such services for children with mental illness under certain circumstances. In addition, the state law sets out the minimum amount of services that must be provided for other diagnoses.

See the mental health section of MassLegalHelp for more details on Mental Health Parity.

Most employer-based insurance plans are covered by parity. There are, however, some employers who are large and self-insure. The plans of these employers are not covered by parity.

Next: What if the private insurer denies my appeal?