Appealing a denial of care by a private insurance company

You should get a denial notice telling you why the insurance company won’t 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, 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 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. Be sure to include:

• Your full name and your policy number
• The exact name of the service your provider requested, over what time period the service was requested (for example, from November 15, 2004 through March 14, 2004),  and whether you would like the service you are receiving to continue while the decision is being appealed
• The 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. 

Plans often publish info on how to file appeals. Click on the links below to find their descriptions of appeal processes:

Tufts - click on the Utilization Management Policy Manual and the go to Chapter 13.

A private  insurance company must decide within 30 business days of when it received your appeal.  If you're 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. 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 don’t need to file the letter with the appeal, so don’t wait to appeal! 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

Make sure the services you want are covered. Insurance companies usually won't 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.

Here are some links to insurance company criteria:

• United Behavioral Health (Group Insurance Commission and as of Jan. 1, 2007, Harvard Pilgrim Health Care): 
• Fallon Community Health Plan (Beacon Health Strategies):  Select "FCHP." Click on resources in the red box toward the top of the screen and then click on "level of care criteria" in the white box with red print. You'll have the option to open the criteria in PDF form or download Adobe Acrobat and then open the criteria.
• For Neighborhood Health Plan (also Beacon Health Strategies). Select "NHP." Click on resources in the red box toward the top of the screen and then click on "level of care criteria" in the white box with red print. You'll have the option to open the criteria in PDF form or download Adobe Acrobat and then open the criteria.
• Blue Cross Blue Shield Massachusetts: a description of Behavioral Health Policy: Psychological Testing & Neuropsychological Testing; a description of Behavioral Health Policy: Outpatient Psychotherapy; and a definition of medical necessity (scroll down to M), which is used in determining coverage for inpatient psychotherapy.
• Pacificare (Harvard Pilgrim Health Plan) uses a set of criteria that must be bought. Pacificare will provide pages of the criteria to a doctor or therapist on a case by case basis. Pacificare defines a service as medically necessary if it
  • treats a behavioral health condition;
  • is the most appropriate supply or level of service, considering potential benefits and harms to the patient;
  • has been proven to be effective; and 
  • is cost-effective.

Like Pacificare, Tufts only discloses its criteria to doctors and therapists in its network. Tufts only provides the persons it insures with the particular criteria it uses to deny services on a case by case basis. It would be wise to ask your doctor for a copy of these criteria before a service is denied. Aetna also uses a set of criteria it only releases to doctors in its network. Cigna: level of care guidelines may be found on its web page of frequently asked questions, under the definition of medical necessity.

The parity law

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?)