Denied: Telehealth
Accessing Care by Telehealth
Will my health insurer cover telehealth?
It should.
However, there is significant variation as to whether insurers are obligated to cover care via telehealth.
Two steps to learn more:
- Search online for up-to-date information about state laws relevant to your coverage, using these search words: [Your state] MENTAL HEALTH INSURANCE TELEHEALTH COVERAGE
- Ask an insurer customer service rep about their obligation to pay for use of telehealth and for any documents related to telehealth care, including:
-
- Are telehealth providers an alternative when there is no in-network provider?
- If I have already been accessing care by telehealth, when can that care be denied?
- Are some levels of care covered (for example, out-patient visits) and others not covered (for example, higher levels of care)? If so, why is there a difference?
- It is always recommended to document your call with a customer service rep:
- The name and ID number of the person you talked with,
- The date, and
- Detailed notes from the discussion.
Potential reasons for pursuing CONTINUED coverage of care by telehealth
If you have had coverage of telehealth and then encounter obstacles to insurance coverage for CONTINUED access, you may have to advocate for why coverage SHOULD continue, such as:
- Continuity of care should be a top priority
- There is no in-person provider available nearby and with appointments soon.
Potential reasons for pursuing NEW coverage of care by telehealth
Care by telehealth may be suitable when:
- There is no in-network, in-person provider available based on medically necessary needs, location, and appointment availability
- Scheduling constraints are avoided; or
- Clinician and/or patient prefer a telehealth appointment
Can an insurer require that I use telehealth instead of in-person?
This possibility varies by insurance plan and by state.
As with all networks, insurers generally offer a range of potential providers to meet the needs of their members, both in-person and by telehealth.
It should.
However, there is significant variation as to whether insurers are obligated to cover care via telehealth.
Two steps to learn more:
- Search online for up-to-date information about state laws relevant to your coverage, using these search words: [Your state] MENTAL HEALTH INSURANCE TELEHEALTH COVERAGE
- Ask an insurer customer service rep about their obligation to pay for use of telehealth and for any documents related to telehealth care, including:
- Are telehealth providers an alternative when there is no in-network provider?
- If I have already been accessing care by telehealth, when can that care be denied?
- Are some levels of care covered (for example, out-patient visits) and others not covered (for example, higher levels of care)? If so, why is there a difference?
- It is always recommended to document your call with a customer service rep:
- The name and ID number of the person you talked with,
- The date, and
- Detailed notes from the discussion.
If you have had coverage of telehealth and then encounter obstacles to insurance coverage for CONTINUED access, you may have to advocate for why coverage SHOULD continue, such as:
- Continuity of care should be a top priority
- There is no in-person provider available nearby and with appointments soon.
If your telehealth provider has left the insurance network, continued coverage may be more challenging.
Care by telehealth may be suitable when:
- There is no in-network, in-person provider available based on medically necessary needs, location, and appointment availability
- Scheduling constraints are avoided; or
- Clinician and/or patient prefer a telehealth appointment
This possibility varies by insurance plan and by state.
As with all networks, insurers generally offer a range of potential providers to meet the needs of their members, both in-person and by telehealth.
Next Steps With Your Insurer
If your insurance policy or state law seems to require access to telehealth coverage
Contact an insurer customer service rep to try resolving the denial, using these talking points:
- “I have been denied access to telehealth care.”
- “My coverage should include telehealth based on….” [describe your reasons, whether information provided by a previous customer service rep or information about state laws.]
- “Please confirm in writing that the claim submitted will be covered by my insurance plan.”
- “If this cannot be confirmed while on the phone, please confirm coverage within 3 business days.”
- “This is not an appeal. This is a request for correction of an improper denial.”
Be sure to document the name of the insurer customer service rep and date of the call.
If this does not result in a timely resolution, then see “Filing a formal complaint with your insurer” for a next step.
If telehealth solves the problem of no available in-network provider
See “No in-network provider” for guidance
If telehealth solves the problem of access to specialty care not available in-network
See “Denied: Not Medically Necessary” for guidance on documenting the required care; this may require also demonstrating “No in-network provider”
Contact an insurer customer service rep to try resolving the denial, using these talking points:
- “I have been denied access to telehealth care.”
- “My coverage should include telehealth based on….” [describe your reasons, whether information provided by a previous customer service rep or information about state laws.]
- “Please confirm in writing that the claim submitted will be covered by my insurance plan.”
- “If this cannot be confirmed while on the phone, please confirm coverage within 3 business days.”
- “This is not an appeal. This is a request for correction of an improper denial.”
See “No in-network provider” for guidance
See “Denied: Not Medically Necessary” for guidance on documenting the required care; this may require also demonstrating “No in-network provider”
What Else? Further Steps
Why file a complaint?
- The goal of filing a “formal complaint” is to escalate an issue towards overcoming whatever obstacle is blocking access to care.
- Filing a formal complaint with your insurer may be helpful (even required) before additional actions, such as filing a complaint with a state insurance regulator.
What a complaint is not?
- A “formal complaint” is NOT an appeal.
- If you are asked whether you want to file an appeal, your response should be: “No, I want to file a formal complaint. This is not an appeal.”
Why file a complaint?
- The goal of filing a “formal complaint” is to escalate an issue towards overcoming whatever obstacle is blocking access to care.
- Filing a formal complaint with your insurer may be helpful (even required) before additional actions, such as filing a complaint with a state insurance regulator.
What a complaint is not?
- A “formal complaint” is NOT an appeal.
- If you are asked whether you want to file an appeal, your response should be: “No, I want to file a formal complaint. This is not an appeal.”
