Tips for talking to your insurer

Anyone living with mental illness knows how frustrating calling your insurance provider can be; repeating yourself constantly, defending your right to have the services and the medications that you need.  Below is a helpful “How-to” of tips and important things to do during your next phone call with your insurance plan.

If you need more help, call the Rhode Island Insurance Consumer Hotline housed at the RI Parent Information Network at 401-270-0101. The hotline is hosted by the RI Parent Information Network and is open to all Rhode Islanders regardless of insurance coverage.

Before you call:

• Have your insurance card and any other information you might need in front of you. Most insurers have different phone numbers for medical coverage and mental health coverage. Make sure to call the correct number for mental health, it is typically on the back of the card.
• Write down what you need to address and the questions you want to ask before you pick up the phone.
• Make sure you have set aside enough TIME. The phone call could be easy; or you might be on the phone for some time. Be prepared either way.
• Have a pencil and some paper ready. Take a nice deep breath.
• Ask for help from family members, friends or other advocates (visit our Resource Page) whenever you need it! Sometimes just having a friend or family member with you when you make your call can make a big difference.

During your call:

• Remember: You are calling because you owe it to yourself to make sure you get the care you need.
• Speak clearly and calmly. Remember that the person on the other end of the call is just doing their job; they have a family and bills to pay, too.  It’s easy to feel angry and upset about having to fight for your right to equal care, but remember the saying, “You can catch more flies with honey than with vinegar.”
• Write down the name(s) of the people you speak with and the date and time of the call(s). Make notes about who said what in case you need to clarify these conversations later when fighting a denied claim.
• Remember to be assertive and DON’T GIVE UP! Self-advocacy means speaking and acting for yourself. It means deciding what is best for you and taking charge of getting it. Being assertive means that you talk respectfully and professionally to others and communicate effectively.
• Speak with the right person. You may get bounced around from one phone number to another. One example of being assertive is to ask to speak with a supervisor (sometimes called a Clinical Reviewer or a Case Manager) if you are not getting what you need from the health plan representative.
• If you are denied, file an appeal in writing. Just by filing an appeal, you greatly increase the chances of your health plan saying yes to the service(s) you want/need. For help in filing an appeal, call the RI Insurance Consumer Hotline housed at the RI Parent Information Network at 401-270-0101 or click here for more about help in filing an appeal. 

 Dealing with Denials and Appeals: 

Your doctor and other health care providers are key to helping you get the health care you need. They are busy individuals so you must be forthcoming and ask for the help you need.

• Letters of Medical Necessity
  The most common reason a health plan will deny a service is that they do not have enough information about you and the service you need. To avoid this problem, ask your doctor or mental health professional to write a letter of medical necessity and send it with the request for service. The letter should have the following:
  • Your medical condition with exact diagnosis.
  • How long your condition will last.
  • Why you need the service and a description of the service.
  • What health problems will occur if you don’t get the service.
  • What other treatment or services were tried, if any, and why they did not work.

The doctor can ask the health plan to call him or her with any questions about the letter. You can also get letters from any health provider or other professional who knows about your condition and why you need the service.

• Medical Records
  Your medical records can help prove to your health plan why you need the service. Ask for copies of your medical records. Ask your doctor to send in copies of medical records that support their letter of medical necessity.Decisions on whether a service is medically necessary are usually made by a doctor who works for your insurance plan. If your service is denied, call your insurance plan and find out what doctor or professional made the decision to deny your service and why. Ask your doctor to call the health plan directly to discuss your condition and the service you need. Sometimes the health plan will change its mind after discussing your situation with your doctor. Getting your health care provider involved early on will avoid denials and appeals and get you the services you need faster.