Insurance companies often make doctors and therapists talk to many different people before they will authorize payment for services.
The first person with whom your doctor speaks is usually called a utilization reviewer. This person may not have the training and experience your doctor has. If the reviewer refuses to authorize care, your doctor may have to speak with another doctor, who, by the way, also may not have the training and experience your doctor has.
If your doctor does not insist that you need the care she requested in the first place, you will not be able to appeal the insurance company’s denial.
Your doctor must tell both the reviewer and the insurance company’s doctor that she will not accept a denial or any reduction of the services she requested for you. If your doctor does not insist on her original request, there is no denial or reduction of services. In other words, if the insurance company gives only part of what your doctor requested and your doctor does not demand all the services in her original request, there is no denial decision to appeal and you lose your appeal rights.
Let your provider know that they must stand up for you through this initial process in order for you to keep your appeal rights.
Sometimes doctors and therapists don’t know that they haven’t started the appeal procedure by speaking with a utilization reviewer or with the insurance company’s doctor. They don’t know that if they don’t clearly insist on the original request, you won’t get a denial notice and will lose all your appeal rights. It’s important that you let your providers know that they must stand up for you through this initial process if you are going to keep your appeal rights. Click here to get a leaflet that you can give to your providers so that they will know how to deal with your insurance company.
If your provider has clearly demanded the services she originally requested, you have the right to appeal any denial.
Next: (if you have MassHealth) How do I appeal a denial by MassHealth?)
Next: (if you have private insurance) Appealing a denial of care by a private insurance company
Produced by Mental Health Legal Advisors Committee Last updated July 7, 2009
