With insurer feedback such as the above, check out Denied: not medically necessary.
Different level of care pushback may look like these:
Maybe.
Best to have a complete copy of your insurance policy. See Action Plan “Request a complete copy of your insurance policy”
Ask a customer service rep exactly where in the insurance policy they see an exclusion or reason to say the care is not covered.
Still not clear? Consider asking for help from your employer or filing a formal insurer complaint.
This may be quite frustrating… whether they are unclear about your care or a claim or a denial.
It may be helpful to have a complete copy of your insurance policy. See Action Plan “Request a complete copy of your insurance policy”
Ask a customer service rep exactly where in the insurance policy they see an exclusion or reason to say the care is not covered.
Still not clear? Consider asking for help from your employer or filing a formal insurer complaint.
We welcome inquiries about other insurance obstacles at [email protected].
Please do not share urgent requests, though we will endeavor to respond on a timely basis. Please do not share personal health information in your email; see our Privacy Policy.
Cover My Mental Health does not provide medical or legal advice.
Inquiries about other insurance obstacles may help us to expand and improve the resources provided on this site. Thanks.
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:
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.
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.
Lastly, suggestions for what to say to an insurer customer service rep are provided on the website (see medical necessity denials).
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:
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.
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.
Lastly, suggestions for what to say to an insurer customer service rep are provided on the website (see medical necessity denials).
Experts point to many explanations for this, including:
…to name a few reasons
Despite these explanations, there is growing recognition that mental health is simply another part of health… and that access to care can and must be improved.
In some cases, that is true.
Still, many individuals and families encounter significant obstacles to care including finding suitable providers or facilities with availability and getting services covered by health insurance.
Three emerging developments have significant potential to improve insurance access:
Send your question to [email protected] and we’ll try to respond… and perhaps include your question in this FAQ resource.
Cover My Mental Health NFP provides education and guidance with respect to dealing with denied health insurance claims and other obstacles to receiving mental health care. Cover My Mental Health does not provide legal services or legal advice with respect to those or any other matters. Each individual should review his/her/their insurance policy or plan document thoroughly. Questions and concerns about legal rights and obligations under such plans, policies or applicable law should be directed to a qualified attorney who can provide counsel on alternative steps to ensure all benefits to which an insured is entitled are timely provided.
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