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Treatment of mental illness can be denied by health insurance companies for a number of reasons and using a variety of methods that determine whether a type of treatment is considered medically necessary or a part of your benefits.
If you are entitled to a specific service or support, you have the right to appeal the decision from the insurance company. Many people are able to receive the care they need after they appeal. If you feel you are being denied care unfairly, there are federal and state laws to help protect you.
Getting denied for a needed mental health care service or treatment can be a frustrating process. Part of what adds to this stressful time is the confusing terms that insurance companies use. Below are definitions of some of the most common terms used when health services are denied.
You may want to appeal your denial simply because you think—based on your care needs and your benefits—that you should get the service. You can also file an appeal if you think that treatment is not being considered equal to other health conditions. The equal treatment of mental health and other health conditions under insurance plans is referred to as mental health parity. Most health plans are required to follow federal and state mental health parity laws.
Below are signs that you may have grounds to appeal a decision by your health plan under parity law.
Certain types of mental health treatment services get denied at higher rates than other health conditions. If you are denied the following supports and services and you think you are entitled to them under your health plan you may want to consider filing an appeal.
All plans must have an external review process to keep appealing if you have completed the health plan's internal appeals process and are not satisfied. Contact your state insurance division for help.
The Federal Center for Medicaid and Medicare Services (CMS) can also enforce parity if states do not enforce the law. If you have concerns that your insurance plan is not following parity, contact the CMS help line at 1-877-267-2323, extension 6-1565.
If you have a self-insured plan—a plan where the employer assumes the financial risk for providing health care benefits to its employees—the U.S. Department of Labor (DOL) has authority to enforce parity. To find out more, call the DOL’s toll free number at 1-866-444-3272 or contact a benefit advisor in one of the DOL regional offices.
If you have a health plan under Medicare or Medicaid there are different appeals processes. Contact your plan for details.
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