What to Do If You're Denied Care By Your Insurance | NAMI

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.

Understanding Insurance Terms

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.

  • Medical necessity criteria are standards used by health plans to decide whether treatments or health care supplies recommended by your mental health provider are reasonable, necessary and appropriate. If the health plan decides the treatment meets these standards then the requested care is considered medically necessary.
  • Utilization review, also known as utilization management, is the process used by insurers to decide whether the requested mental health care is medically necessary, efficient and in line with accepted medical practice. In line with accepted medical practice means that the mental health treatment or service is proven to be effective based on scientific evidence.
  • Prior authorization, also known as pre-approval, preauthorization, prior approval or precertification, is a type of utilization review and is when you or your service provider must ask for approval before your health plan will agree to pay for a service, treatment plan or prescription drug.
  • Step therapy is a type of prior authorization in which you must try a less expensive prescription drug or service before you can move to a more expensive prescription or service.

Signs That You May Want To Appeal Your Denial

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.

  1. Higher costs or fewer visits for mental health services than for other kinds of health care.
  2. Having to call and get permission to get mental health care covered, but not for other types of health care.
  3. Getting denied mental health services because they were not considered medically necessary, but the plan does not answer a request for the medical necessity criteria they use.
  4. Inability to find in-network mental health providers that are taking new patients, but you can find providers for other health care.
  5. The health plan will not cover residential mental health or substance use treatment or intensive outpatient care, but it does for other health conditions.

To learn more about parity appeals, please download this guide from NAMI and The Kennedy Forum.

Commonly Denied Types Of Care

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.

  • Residential treatment for mental illness
  • Intermediate levels of care, such as intensive outpatient treatment, psychological rehabilitation, partial hospitalization and assertive community treatment (ACT)
  • Office based diagnostic and treatment interventions, such as diagnostic assessments, standardized tests like the Patient Health Questionnaire 9 (PHQ-9), which measures depression, and other services like psychotherapy

What To Do If Your Insurance Plan Isn’t Cooperating

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.

NAMI HelpLine is available M-F, 10 a.m. – 10 p.m. ET. Call 800-950-6264,
text “helpline” to 62640, or chat online. In a crisis, call or text 988 (24/7).