In summary
Government agencies can overrule an insurance company’s denial of coverage for a medically necessary mental health treatment, but figuring out how to appeal can be complicated.
Your request for mental health treatment coverage was denied by your health insurance carrier.
Now what?
We asked representatives from state and federal agencies that regulate health insurers, along with representatives of the insurance industry, to give us a few pointers on what people should do next.
You can file an appeal that might lead your health insurer to reverse its decision, and if that fails, you can ask a government agency to review your case and potentially overrule the insurer.
Two different departments in California regulate health insurance carriers: the Department of Managed Health Care and the Department of Insurance. Some health plans are not regulated by the state, but instead by the federal Employee Benefits Security Administration of the U.S. Department of Labor.
Coverage requirements can be different. Plans regulated by the federal government don’t have to adhere to California’s most recent mental health coverage law.
In most cases you first need to file an internal appeal with your health insurance carrier. If you can’t figure out how to do so, the Department of Insurance recommends using a “Control-F” search online to look through your evidence of coverage for the word “complaint” or “complaints.”
In some cases, you can skip the internal appeal and instead go right to the Department of Managed Health Care. That’s possible when there’s an immediate threat to your health, or if you were denied authorization because you were seeking an experimental treatment. The Department of Insurance does not require consumers to exhaust all internal appeals before reaching out for help.
If you have completed the internal appeals process with your health plan and are still denied treatment authorization, you don’t have to give up. Your next step is to file for an independent medical review. In those reviews, outside experts review cases for the state to determine whether a health insurance carrier rightfully denied treatment.
To figure out which regulator to appeal to, try calling your health plan or looking in the paperwork provided by your insurance carrier. And, if you still can’t figure it out, you can reach out to one of the state departments — they say they will eventually get independent medical review requests to the right place.
To file for an independent medical review with the Department of Managed Health Care, which regulates the majority of state plans, go to this website.
To file for an independent medical review with the California Department of Insurance, start at this website.
To contact the Employee Benefits Security Administration, try askEBSA.dol.gov or 1-866-444-3272
More information about the appeals process can be found at this website from the U.S. Centers for Medicare & Medicaid Services .
And at this site from the Department of Labor.
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