When you are seeking treatment coverage for your child’s substance use disorder or mental health issue, it is critical to document every action you have taken for insurance and medical purposes.
What many parents don’t know is that your insurance provider has to cover your child’s substance use disorder. It’s actually the law. Even though your child’s health care provider has recommended a particular treatment, this may be denied by the insurance company. If this occurs, there are things you can do and this article should be helpful in explaining your options.
If you have any claims that will require appeals, mediation, or litigation, you need to have all necessary evidence to back up your claim. As there are deadlines for appeals and for filing a lawsuit, these documents contain important dates.
Call the insurance company and request that they send you a copy of your plan or policy as well as the claims file which contains denials and records of the review of the requests for treatment. In all likelihood, you will need to request these documents in writing so make certain you ask how to obtain both your plan and the claims file. For many plans, you must send a letter to the plan administrator requesting the entire claims file, including copies of the policy and all decisions the insurance company has made regarding treatment requests.
Although this information should be in your plan or policy you should ask the representative what you need to do to obtain your file and where you need to send that request.
Keep record of any conversations with the insurer. Details matter. Keep every email record and try to have as many conversations confirmed in writing as possible (see below about phone calls).
It’s also really important to keep record of anything you need to show to the insurance company in order to file a claim or appeal. Keep medical bills, receipts of payments, and explanation of benefits received from the insurance company.
Don’t assume you will remember all of the nuances of your phone calls without writing down every detail scrupulously. Keep track of the names of the people you spoke to, the dates and times you spoke, as well as what you specifically spoke about, and confirm information at the end of each call. If possible, request a follow-up confirmation email in writing, or write the confirmation email yourself to create a paper trail.
Sometimes insurance company representatives may state something technical or something you do not understand. If there is anything you don’t understand , ask the representative to please walk you through the details – how a certain claim was processed, why a certain claim was denied, and how this reflects your benefits. Again, document everything they tell you. (To help you follow along with some of the technical language used by insurance companies, you might find this glossary useful.)
You have the right to appeal any denial of care. You should take advantage of the right to appeal. Failing to appeal may limit or even eliminate your ability to file a lawsuit should your child not be approved for treatment.
Generally, individuals have at least one internal appeal, which is a request to the insurance company to re-consider a denial. You should speak with your child’s physician regarding the denial and have him or her determine if there is any missing medical information that could support your appeal. Note that there are deadlines for the appeals, so you must read the denial letter and your policy to determine the deadlines for submission.
If you receive an internal appeal denial, generally, an external appeal will be available, which may be through your state or through your plan. The external appeal is the request for someone other than the insurance company to review all the documents and make a new determination. External appeals also have deadlines for filing. Although many plans have two levels of internal appeal, the time for filing an external appeal for many plans begins to run after the first internal appeal. For example, New York has a deadline for filing an external appeal within four months after the first internal appeal denial.
If you still are faced with a denial after the appeals, you can consider litigation. Keep in mind that you may be limited to the documents which you submitted during the appeals so the appeal needs to be as detailed and supported by as comprehensive medical information and records as possible.
If you feel you’ve submitted all of the proper documentation and you’re still having issues, insurance departments and state offices of the Attorney General are available to receive and attempt to resolve insurance problems. The resources available depend on what state you’re in.
When it comes to submitting and responding to insurance claims for your child’s substance use disorder treatment, time is of the essence, so it’s really important to take action immediately. You’re your child’s best advocate in this fight.