– Denials Management, Inc. has just published The Health Insurance Appeals Guide to inform consumers and treating providers on the key steps when filing appeals for denials of mental health and substance use disorder (MH/SUD) treatment services. It was written by leading health insurance experts to help educate individuals about their appeal rights and explain the steps in the appeals process.  Complimentary copies of the Guide can be downloaded here.    

“A primary goal of The Health Insurance Appeals Guide is to empower individuals to better understand their rights to file a health insurance appeal”, notes Mary Covington, President, Denials Management and co-author. “Whether the individual is a patient, provider, family member, caregiver, or advocate, our shared health care goal is to get the right care to the right patient at the right time. Unfortunately, this is easier said than done. The health insurance system in the United States is complex and confusing. Individuals are often denied coverage by their insurance companies for needed treatment, even though, in most cases, insurers have a contractual and regulatory responsibility to cover and reimburse for evidence-based care that improves a patient’s clinical outcome.”

“Through a system of managed care, health plans can make ‘medical necessity’ or other types of coverage decisions that lead to denials. Sometimes these decisions are made for the right reasons—and prevent patients from receiving dangerous or unnecessary care—but, far too often, these decisions are made with subjective reasoning,” adds Garry Carneal, JD, MA, President and CEO, Schooner Strategies and co-author. “In these cases, patients are left without access to care or are stuck with medical bills they often cannot afford.  Therefore, this Guide serves as an invaluable resource to help consumers and others navigate the appeals process.”

“Recognizing the importance of health care decisions in the lives of their constituents, federal and state regulators created a health insurance appeals system to provide an opportunity for people to challenge denials. The process of questioning an insurance company’s decision, or lack thereof, related to an insured’s health care needs has come to be known as the ‘insurance appeals process,’” remarks Justin Eckman, Director of Client Operations, Denials Management and co-author.  “It is this process that the Guide seeks to explain.”

The publication is made up of the following sections to help consumers understand the pathway to file a health insurance appeal after a denial of care:

• Definitions.  Part I includes a list of key acronyms and defines commonly used insurance and appeals terminology.
• What is health insurance?  Part II offers important background information about health insurance and helps individuals determine what type of health plan they have. This information is necessary to understand before filing an insurance appeal because the plan type will determine what appeal options a patient has, as well as the regulatory bodies charged with overseeing the health insurer and maintaining the integrity of the appeals process.
• What should individuals know before filing an appeal?  Part III contains information about the administrative and clinical appeals process. The Guide explains the different levels of appeals, as well as the ways in which insurance denials and appeals are broadly categorized and handled. Understanding the different types of denials and appeals procedures can help individuals better understand how the process works and draft a more effective appeal.  
• How does mental health parity affect appeals?  Part IV explores the landmark Mental Health Parity and Addictions Equity Act of 2008 (MHPAEA), also known as the Federal Parity Law, and explains its significance concerning appeals. The history of the Federal Parity Law and related efforts are discussed, as well as the many ways in which insurance companies have historically failed to fully comply with the law. This section also explains how to assert and prove a parity violation, while leveraging the MPHAEA in appeal letters.
• Preparing an appeal – What’s next?  Part V focuses on best practices for drafting an appeal letter and provides appeal advice for the denial classifications identified in Part III of the booklet.
• Final thoughts.  Part VI offers some final thoughts on the health insurance appeals process.
• Resources and FAQs.  Parts VII and VIII of the booklet provide important resources for appeal writers, including lists of frequently asked questions (FAQs) and additional resources.  For consumers who need additional help regarding a mental health parity violation, check out www.parityregistry.org.

This publication was sponsored in part by Schooner Strategies. 

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About Denials Management, Inc. – www. fixmyclaim.com

Facing medical, behavioral health, or substance abuse issues can be emotionally challenging and financially stressful for families. Similarly, we understand that providers must focus on the treatment of their patients rather than navigating through complicated utilization review, claims, and appeal processes. Since 1990, Denials Management, Inc. has been partnering with families and providers to assist in resolving the specific insurance problems they are facing. Our experienced medical insurance advocates offer a variety of services, such as claims management, fighting insurance denials, and much more.  For more information Denials Management, visit www.fixmyclaim.com or email us at intake@denialsmgt.com.