September 11, 2020

By Cari Schwartz, Esq.

Dealing with your insurance company to get mental health treatment covered can be confusing and complicated.
I work at a law firm that represents people with mental health conditions when their health plans refuse to pay for treatment. Often, these insurance companies claim that mental health treatment is "not medically necessary," which is, of course, inaccurate.
Below are some tips to help you maximize coverage for your mental health care.

Know Your Coverage

There are two types of health insurance coverage: ERISA and Non-ERISA. ERISA stands for Employee Retirement Security Income Act. This is health insurance that is obtained through an employer (even if you pay some of the premium). ERISA is meant to protect individuals and requires health plans to comply with procedures for denying claims and appeals. If you have an ERISA plan, you should request a copy of your insurance policy from your employers’ human resources department.
Non-ERISA benefits or individual insurance is purchased privately through an insurance agent or through an exchange (you pay the entire premium) or benefits may be from a government or religious employer exempt from ERISA. With this plan, you can request a copy of the policy from your insurance company, or in certain cases, from your employer.
Once you have a copy of your insurance policy from your employer or the insurance company, read it as thoroughly as you can and do your best to become familiar with it.

Pay Attention to Important Plan Terms

Reading a health insurance policy can get confusing very quickly. Below are some important plan terms that you will likely see in your policy. Make sure you understand what these terms mean, and how they apply to your situation, before you get mental health treatment.

  • Precertification or pre-authorization: Your policy may require precertification or pre-authorization (the process of gaining approval for coverage) for certain services before you receive them, except for emergency services. However, this does not guarantee that your health insurance or plan will cover the cost of the treatment.

  • Deadlines: Every insured person has an obligation to submit claims to the insurance company in a timely manner. Make sure you know how much time you have to submit your claims. Timeliness gives the insurance company enough time to fully investigate the claim. This also benefits you because it may result in a prompt payment of your claim.

  • Appeals: If you are denied coverage, you may be able to file for an appeal, or a reconsideration of the decision. However, there may be a limit on the amount of appeals you can make, so it’s important to know how many appeals are allowed under your plan and what the deadline is to submit them.

  • Statute of limitations: Some policies include a statute of limitations, which is the amount of time you have to file a legal action or bring a lawsuit. If the plan does not specifically include a statute of limitations, then state laws will determine the timeframe. For example, the statute of limitations in California for breach of contract is four years.

  • Binding arbitration: Non-ERISA plans may have a provision for binding arbitration. Arbitration is when a neutral third party, called an arbitrator, hears evidence and then makes a binding decision. Once the arbitrator makes a decision, it is final, and the insured cannot file a legal action or bring a lawsuit.

  • Residential treatment center: The plan might set forth their own definition of a residential treatment center. This is important to know before entering treatment.

Be Aware of Medical Necessity Guidelines

Mental health benefits are only provided for services that are deemed “medically necessary.” Insurance companies have developed medical policies or guidelines for mental health treatment. Most insurance company guidelines set forth criteria for acute inpatient treatment, residential treatment, partial hospitalization treatment and intensive outpatient treatment. Typically, the criteria are different for admission and continued stay.
Some guidelines are available on insurance company websites, but in some cases, you may need to ask for them. Familiarize yourself with the medical necessity guidelines and apply them to any explanations of your treatment. Consider the question: what makes the treatment medically necessary based on the guidelines? If you are submitting an appeal, then make sure to clearly explain this answer.

Understand Appeals and Denials Rights

Understand your appeal rights and appeal deadlines. These will be provided in your policy and attached to any denial letters. Put your appeal in writing and submit it on time with a method of delivery confirmation. It’s also helpful to submit treatment records with your appeal. Even better, submit a letter from your treatment provider explaining why your treatment is medically necessary based on the insurance company’s guidelines. You can also submit a post-service claim if the denial was pre-service or during treatment.
Navigating insurance denials for mental health treatment can be incredibly overwhelming. However, knowledge is power in dealing with insurance companies. Make sure to learn the details and don’t hesitate to enlist help if needed.
Cari Schwartz is a senior associate with Kantor & Kantor, LLP. Kantor & Kantor is a contingency law firm that works with individuals and their families to ensure health benefits get paid. Cari represents clients seeking health benefits pursuant to individual policies with a specific focus on mental health benefits.

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