The following is an example of how to dispute a rejected claim for substance rehabilitation treatment through your insurance company. For questions specific to your own insurance options, claims and coverage, it is best to contact Intervention Helpline for a thorough review of your issue.
Determine Why Your Claim Was Denied
As a policyholder, you have a right to know why your claim was denied, and your insurance provider has an obligation to explain that denial in terms that you can understand. Typically, a denial will come in the form of a letter from your insurance company, outlining your EOB, or Explanation of Benefits. Any questions or ambiguity that arises from letter should be addressed with your insurer.
Check For Clerical Errors First
Read through the denial documents and determine if there was a clerical error, sometimes claims can be denied because of simple mistakes like a wrong address, ID number or service date. If you find such a mistake, contact your insurance company and note the correction. If there was an error on the part of your medical provider, contact the office and alert them of the mistake.
Gather all the evidence you can to prove that the services received were within your coverage spectrum and medically necessary. Compile any relevant information, including treatment, prescriptions, and medical history. This might entail contacting your provider and either requesting records on your own, or signing information releases authorizing your health provider to disclose those records to the insurer.
Challenge The Claim In Writing
Check with the insurance company’s website first. You may need to send a letter, along with a standard appeals form to initiate the challenge process. Include your claim number and insurance ID, and briefly convey your issue and proposed resolution to the claim. Be polite, professional and assertive. Ask for a record that the letter was received. It might be wise to send it certified USPS, Fed-Ex, or UPS.
Be Aware Of Time
Your right to appeal is finite and will vary based on coverage provider and the type of claim. It’s important to understand how long you have to file an appeal, and what timeframe you can expect to hear back. If a claim is denied, the best step is to initiate the appeals process as soon as possible, no more than a day or two after receiving the letter.
The person on the other end of the phone is human too. Getting a claim denied can be a scary process, potentially costing thousands of dollars, if not hundreds of thousands – a denial can ruin your credit, and severely affect your finances. But it’s important to remain calm, listen carefully, ask the right questions and take the proactive steps necessary to graciously resolve your claim.
Exhaust Your Legal Remedies
If you navigate through each and every review step with your insurance company, and the claim is then denied for a second time, you still have the right to an external review under the Affordable Care Act. For more information, search External Review at Healthcare.gov. It is stated that standard reviews at Healthcare.gov are decided no later than 60 days after they are received.
Mental Health Parity And Addiction Equities Act
In 2008, a sweeping law was enacted at the federal level expanding access to mental health and substance addiction treatment for patients across the country. Parity refers to equal, and prior to the passage of this law, physical medical conditions received disproportionate coverage compared to mental health and substance use conditions. This disparity served as an obstacle for individuals in need of help-seeking to receive treatment for their disorders.
However, insurance companies still routinely deny or dispute claims that are protected under the MHPAEA. It is important to know your rights and to file a challenge if you feel those rights have been violated.
According to the National Alliance on Mental Illness, below are a few warning signs that might indicate your rights have been violated under the MHPAEA:
- Higher Costs. You are incurring higher costs or are allocated fewer visits for mental health services than for other types of health care.
- The insurance company is requiring you to call and get permission before covering mental health care, but not requiring the same permission for other health care services.
- Denial due to Medical Necessity. Mental health claims are being denied because they are not considered medically necessary
- Can’t find in-network care. An inability to find in-network mental health providers willing to take on new patients – but you are able to find providers for other health care.
- No residential or intensive outpatient coverage. Your health plan does not cover residential mental health or substance use treatment or intensive outpatient care, but it does for other health conditions.
An intervention professional can advise you or your family on treatment options, and common insurance issues that tend to arise. It’s important to ensure every aspect of your treatment that can be covered, is approved from the onset of the recovery process. Treatment trajectories can be complicated, span more than a year in length, and intersect with multiple health care facilities and organizations. It’s important to begin the process with relevant, reliable, and comprehensive information.