Pushing Further with your Insurer
Appeal
- Appeals are legal actions specifically described in your insurance plan, including the time limits for submitting an appeal.
- Appeals are your opportunity to provide specific evidence supporting your position that the insurer got it wrong. That means in writing, NOT over the phone with a customer service rep.
- Appeals can be the key step toward success; even if the appeal is not successful, submitting evidence in an appeal is critical in order to take further action against the insurer.
- Appeals processes are specified in your insurance policy and must be followed.
- A range of “helpers” may be available to support your filing an appeal such as claim advocacy organizations and attorneys. Since appeals can be complex and can affect potential litigation if the appeal is denied, handling the appeal on your own behalf without assistance may not be your best choice.
Cover My Mental Health provides background about appeals, though it does not offer specific templates or legal advice. Each insurance policy and medical situation requires an individualized approach to determine the content and form of the appeal.
- Try to resolve the dispute in discussion with an insurer’s customer service rep.
- File a formal complaint with your insurer (a “complaint” is not the same as an “appeal”).
- File a complaint with your state insurance regulator or contact the U.S. Department of Labor if your insurance is an employee benefit of a private company.
- Consider asking your employer to advocate for you with the insurer.
- Before appealing, you should request from your insurer a complete copy of their claim processing documentation. Share any medical reports generated by the insurance company with your clinician to determine whether your clinician disagrees and how best to document that disagreement (for example, with a specific medical necessity letter).
Still no resolution? Still believe the insurer made a mistake? Then filing an
appeal may be the right next step.
- Search “appeal” in the complete insurance policy; that document may be called a Summary Plan Description (SPD), Certificate of Coverage (COC), Evidence of Coverage (EOC), or similar name; it is likely more than 100 pages long.
- The denial letter from your insurer should describe your right to appeal (as included in your insurance plan) and the steps you need to take
- You can also ask an insurer customer service rep for detailed information about your rights to appeal. Be sure to document any information you receive and the name of the person who provided it.
- The appeal process may involve multiple, internal reviews or levels (such as “first level” appeal, “second level” appeal) that are evaluated by the insurer.
- The appeal process must begin with such internal reviews, made directly to the insurer. The appeal process also likely includes the possibility of an “external” review after any internal reviews have been tried without success.
- Your insurance plan may limit your number of appeals.
- Summary of your appeal; specific evidence in support of your assertion that the insurer has made a mistake, such as medical records and reports.
- Evidence of your medically-necessary care; this may be best provided with a letter of medical necessity from your provider to be submitted as an attachment.
- Flaws in the insurer’s processes or their conclusions, such as:
- Insufficient or mistaken evidence to support their conclusion regarding medical necessity,
- Insufficient or mistaken evidence regarding their conclusion regarding levels of care,
- Overruling your clinician’s decision without data or a clinically-relevant reason,
- Their reviewer lacked appropriate qualifications to make an assessment.
- Insurer’s non-compliance with relevant laws and/or regulations or with published treatment guidelines
- Evidence of your having acted appropriately in pursuing necessary care, together with evidence of the insurer’s actions that have interfered with your care.
| Potential “helpers” | Potential advantages | Potential disadvantages |
| Clinicians |
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| Health insurance appeals services |
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| Lawyers |
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| Patient advocates |
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| AI-based appeal preparers |
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| Insurance company customer service |
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External Review
- External reviews must typically be conducted by a clinician with the same area of expertise and credentials as the provider treating you.
- For example, claims for care from a child psychologist with expertise in depression likely must be reviewed by a child psychologist with expertise in depression.
- An external review can be initiated through your state’s insurance regulator.
- External reviews will likely follow very specific steps, spelled out in your insurance policy or according to the state insurance regulator, including:
- Timeline for the review
- Documentation available to you following the review; this may include the clinical standard used for a medical necessity determination
- Qualification and (possibly) identity of the clinician who completes the review
- External reviews have a reasonably good success rate.
- Having a letter of medical necessity from your provider will, of course, by helpful In disputes related to medical necessity.
- If the external review is not successful, there is no restriction on your requesting (in writing) detailed information from the insurer about the review towards understanding their review.
Cover My Mental Health provides background about external reviews, though it does not offer specific advice or legal advice. Each insurance policy and medical situation requires an individualized approach to determine the content and form of the appeal.
- Search “appeal” or “external review” in the insurance policy; that document may be called a Summary Plan Description (SPD), Certificate of Coverage (COC), Evidence of Coverage (EOC), or similar name; it is likely more than 100 pages long.
- The policy should include information about your rights to an external (or independent) review and the process to be followed.
- You can also ask an insurer customer service rep for detailed information about your rights to an external (or independent) review. Be sure to document any information you are provided and the name of the person who provided it.
Single Case Agreement
“Single case agreement” means that your health insurer has made a one-time exception to the insurance policy’s governing provisions, agreeing in writing to cover certain claims that they would not otherwise cover.
For example, a single case agreement may be appropriate when:
- The insurer has agreed to certain coverage and services, whether or not the insurer has agreed that the services are medically necessary or should be covered without a single case agreement.
- No in-network provider is available, though they may agree to pay for an out-of-network provider as if they were in-network.
- Your provider has experience advocating for single case agreements and is ready to support you.
To be clear, a single case agreement is an exception agreed to by an insurer. There is no obligation for an insurer to consider or finalize a single case agreement. That said, there will not be an agreement without trying.
- An agreed “exception” – Finalizing a single case agreement does not require you to agree that your insurer should already be covering the claims.
The single case agreement just means that they will cover what is specifically agreed to and at the level of payment the insurer deems appropriate (this will likely not be full coverage at the rate billed). - Include all details – The single case agreement must specify ALL aspects of the coverage and services agreed to
- Your provider may help – Your provider may be helpful in requesting a single case agreement; when the provider has already provided a medical necessity letter., their asking the insurer for a single case agreement is a natural next way they can support you.
- Your employer may help – When your health insurance is an employee benefit, your employer may be helpful in supporting your request to the insurance company. This may require disclosing certain health information to your employer.
- You will have to ask – Single case agreements are not publicized and you will have to ask for one. Expect push-back. Be persistent. There is not likely information in your policy about single case agreements.
Cover My Mental Health provides background about single case agreements, though it does not offer specific advice or legal advice. Each insurance policy and medical situation requires an individualized approach to determine the content and form of the single case agreement.
- Try to resolve the dispute in discussion with the insurer’s customer service rep.
- File a formal complaint with your insurer (a “complaint” is not the same as an “appeal”).
- Exhaust all claim appeals specified in the benefit plan; it may also be required that you pursue independent external review before requesting an insurer consider a single case agreement.
- File a complaint with your state insurance regulator.
- Consider asking your employer to advocate for you with the insurer.
Still no resolution? Then pursuing a single case agreement may be the right next step.
Some providers are experienced with single case agreements and may support your insurance company submission on request.
To pursue a single case agreement directly with your health insurer, use this: Template letter to request single case agreement
Some large companies may consider a request for a single case agreement. Your company’s human resources or benefits department may provide guidance on this possibility.
Lawsuit
- Well-supported medical evidence showing that a health insurance company got it wrong.
- A significant amount of money is at stake:
- Recovery of damages is limited to benefits payable under the terms of the policy or plan and will not exceed out-of-pocket costs and attorney’s fees (particularly for litigation related to coverage as an employee benefit).
- In most cases, no “pain and suffering,” “punitive” damages, or similar recovery is possible as may be the case for certain other litigation.
- You have located an attorney who has significant experience representing individuals (or groups) with litigation related to health insurance:
- Such litigation typically involves “ERISA”-based claims, the federal law related to employer-sponsored benefits; this is a highly-specialized area of law
- Litigation may be possible against an insurer or a large employer operating the health insurance benefit plan
- The required appeal processes as specified in the insurance policy have all been properly followed and concluded. External review is optional, though.
When a specific health insurer dispute seems to have these characteristics, it may be worth exploring potential litigation with an expert attorney.
Cover My Mental Health does not provide legal services or legal advice.
The information above reflects general observations about potential litigation related to health insurance for mental health and substance use disorder care and does not make any representation about likely outcomes or success in litigation.
