"What if…?

Common Insurer Obstacles – What If…

With insurer feedback such as the above, check out Denied: not medically necessary.
Different level of care pushback may look like these:

  • Fewer appointments are approved than the provider has determined is appropriate
  • Only out-patient care is covered, when the provider has determined that intensive out-patient or partial hospitalization is appropriate.
  • At higher levels of care (for example, in-patient), an insurer determines that enough progress has been made, so a lower level of care is now appropriate; the provider does not agree.
  • At higher levels of care (for example, in-patient), an insurer determines that not enough progress has been made, so that care is no longer covered; the provider does not agree.
  • Intensive out-patient care is not covered, but out-patient care is covered

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.

  • See Action Plan for “Tips when talking with insurance company customer service reps”

Still not clear? Consider asking for help from your employer or filing a formal insurer complaint.

Guidance for 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.

  • See Action Plan for “Tips when talking with insurance company customer service reps”

Still not clear? Consider asking for help from your employer or filing a formal insurer complaint.

Guidance for 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.

More Challenging Scenarios – What If…

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 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.
  • 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).

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 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.
  • 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).

FAQs

Experts point to many explanations for this, including:

  • Stigma,
  • Historical exclusion of coverage, and
  • Higher subjectivity in diagnosis and treatment compared with medical/surgical conditions

        …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:

  • New state and federal regulations requiring insurance companies to cover mental health care;
  • Reductions in stigma; and
  • Growing consumer expectations of coverage

    Your use of the resources provided here can make a difference for you and for others.

Send your question to [email protected] and we’ll try to respond… and perhaps include your question in this FAQ resource.