While we cannot offer specific medical or legal advice, here is how the resources of Cover My Mental Health might be helpful. Please consider seeking medical and/or legal advice as appropriate.

This situation combines two insurer obstacles for which we provide actionable resources:

• “Denied: not medically necessary” – the psychiatrist’s assessment of the appropriate care is not accepted by the insurer.
  

  For this obstacle, the downloadable medical necessity letter template can document the psychiatrist’s determination of the required care. The template includes instructions to guide the psychiatrist’s preparation of the letter, including referring to the insurer’s denial that is considered inappropriate.
  
  

• “No in-network provider” – for the recommended care, the next-step required clinician/provider (e.g., intensive outpatient, partial hospitalization, residential) is apparently not available in the insurer’s network.

  For this obstacle, using the downloadable worksheet can document that the insurer’s suggested clinicians have been reviewed (including by the psychiatrist) and are not appropriate to the go-forward treatment plan.
  
  

These two downloadable resources can be shared with your insurer to request their coverage of the required care as required by the insurance policy.

Suggestions for what to say to an insurer customer service rep are provided on the website (see medical necessity denials or no in-network provider).

While we cannot offer specific medical or legal advice, here is how the resources of Cover My Mental Health might be helpful. Please consider seeking medical and/or legal advice as appropriate.

For this obstacle, the insurer’s guidance for your daughter’s level of care differs from the clinical assessment at your daughter’s treatment center.

It may be helpful to think of this as a denial for “not medically necessary” since the insurer is apparently denying the clinical decision of the residential treatment center.

• The downloadable medical necessity letter template may be useful to document the clinical assessment by your daughter’s psychiatrist (or by the most senior clinician at her residential treatment center).
  
  
• The letter might reference the short timeline your insurer is mandating for a change in level of care. For example, include an assessment of the potential danger and the risk to her care and recovery of leaving the residential program.
  
  
• The template includes instructions to guide the preparation of the medical necessity letter.
  
  
• A template transmittal letter is also available to download. That transmittal can be used to share the clinician’s letter with your insurer.

Lastly, suggestions for what to say to an insurer customer service rep are provided on the website (see medical necessity denials).