You Have A Right To Your Appeal
Challenging a coverage denial by a health plan is a legal right guaranteed to all insured people. All plans— including Medicaid managed care, private individual and group insurance policies, and employer sponsored health plans—must provide a clear process for appeals.
Parity laws also guarantee rights to individuals with mental health and substance use disorders intended to make coverage rules more transparent and improve the appeals process. These rights are:
- Plans are required to provide – on your request — the medical necessity criteria they used in evaluating your claim.
- Plans are required to provide a reason for the denial of any claim and how it relates to parity regulations.
EXERCISE YOUR RIGHT TO APPEAL
The appeals process is one way to hold insurers accountable and to exercise our rights under mental health parity laws. More than 50% of health insurance appeals are successful. Just because this process can be long and complicated does NOT mean it should not be done.
It helps if you keep all of your health plan’s coverage information and correspondence in a notebook to help ease the process and organize your appeals materials. Appeals are often not won at the first level. Success is more likely with ongoing and persistent appeals.
KEEP IN MIND…You may have to file your appeal within a specified time period; it is vital that you do so.
Steps In The Appeals Process
Depending on your specific insurance plan, there are typically three levels of insurance appeals. The process requires you to complete each level, before initiating the next and can be resolved at any one of the levels.
If your claim is denied due to a particular service being billed or coded incorrectly, your mental health professional may be able to gather and submit the necessary information on your behalf to resolve the issue without the necessity of a formal appeal.
First Level Appeal or Request for Reconsideration
The goal of the first appeal is to prove that your claim or request for pre-authorization DOES meet the insurance guidelines and that it was incorrectly rejected. You or your mental health professional may contact your insurance company IN WRITING to request reconsideration. Your mental health professional may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer review” in order to challenge the decision which could resolve the issue.
Second Level Appeal
The goal of this appeal is to prove that the request should be accepted within your health plan’s coverage guidelines. Second level appeals are typically reviewed by a medical director of your insurance plan who was not involved in the claim decision.
Independent External Review
External reviews are conducted by an independent, third-party reviewer in collaboration with a professional who is board-certified in the same specialty as the patient’s provider.
NEED HELP IN FILING AN APPEAL? Call Rhode Island’s Health Insurance Consumer Hotline at 401-270-0101.
Learn more about your health insurers appeals process:
NHPRI Process
BCBSRI Process
United Process
Tufts Process
This content is adapted from the following:
Patient Advocates Guide to filing an appeal
Parity Implementation Coalition Toolkit