Appealing Insurance decision - mental health services
Anyone have any advice on appealing a health insurance issue to the state? My child's mental health treatment was approved and then a few months in the insurance company denied payment because the practitioner is not fully licensed. I appealed to the company but they denied my appeal, now I want to appeal to the state but would love to get some advice first. If you would be willing to share any knowledge about the process or tips on a successful appeal I would be very appreciative. Thank you!
Nov 10, 2019
Parent Replies
I would suggest first confirming that you've exhausted the internal appeals available. There is often a second-tier appeal that is reviewed by a higher level person at the insurance company with a policy or regulatory role. Subsequently, you can appeal the coverage decisions by opening a case on the CDI website. While I've successfully challenged a number of coverage decisions, I don't have any experience getting coverage for unlicensed service providers. Generally speaking though, I would suggest that the persuasiveness of the arguments that you present in your appeal letter does have an impact on the outcome of your appeal.
Is this an outpatient provider? I am an LCSW and was told when I was Pre licensed that MSW or AMFTs services are not always reimbursed by insurance. Many Pre licensed individuals offer sliding scales for this reason. I'm sorry this happened
I’m sorry you’ve been struggling to get coverage for your child. The therapist should’ve been working under someone else’s license if he/she/ they are not licensed yet. Double check that there is no supervisor whose license can be used for billing. Otherwise, I don’t think you will win the appeal. If the therapist did not disclose that they are unlicensed you can ask for reimbursement from the therapist. There may be both legal and ethical issues involved.
Make sure that you appeal the decision as high up as you can with the insurance provider, and also file a complaint with the provider. I filed a complaint with Kaiser and they immediately refunded my co-pay and bill for the service.
If that doesn't work, gather all the evidence you can of the treatment approval and then subsequent denial. Have paperwork from all the appeals and complaints, too. File an IMR here: https://www.dmhc.ca.gov/FileaComplaint.aspx.
I had success in appealing to the state once. An ambulance bill was sent to the wrong address due to a typo, so I never received it. Three years later, I moved and received the bill. Since this was after the 2 year window for filing claims, the insurance company, Blue Shield, denied my claim for the old bill. Appeals to Blue Shield were also denied. I filed an IMR. The decision was that while Blue Shield was within their right to deny the claim, it would be covered given the circumstances.
Good luck!