The Denial Notice
First, you should get a denial notice telling you why MassHealth (or a MassHealth HMO or Massachusetts Behavioral Health Partnership, all referred to as the "insurer") won’t pay for the services requested. 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, gives 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 should say more than that the services requested are “not medically necessary.”
The notice should provide some specific facts about your case that show why the requested services are not necessary for you in particular. If you don’t get a notice that sufficiently describes why the services were denied, you can write to MassHealth asking for an adequate notice or you can call the Mental Health Legal Advisors at 617-338-2345 ext. 29 and an attorney will help you get an adequate notice.
Filing your Appeal
Once you have any denial notice, file an appeal immediately.
If it is for the continuation of services you already are receiving and you file the appeal within 10 days of receiving the denial notice, you can 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.
Ask your provider to give the insurer a letter that supports your appeal.
You don’t need to file the letter with the appeal, so don’t wait to appeal. However, the insurer must decide within 5 business days of an appeal, so you should ask your provider for the letter 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.
Boston Medical Center (BMC) Healthnet gives a general definition of medical necessity and how to support a request for services on its website. It's a good idea for your provider to check your insurer's criteria for care and then use the language in those criteria in her request for services.