If you don’t understand your insurance benefits…
- Read your policy
- Check to see if the treatment providers you are seeking are willing to help you navigate coverage
- Consult an insurance representative; ask for the “Manager of Benefits”
- Make sure to have a paper and pen or a computer to record everything that you will be told
- Make sure to include the date and the time and name of the represenative you are talking to
Determine what type of benefits that you have
Ask the following questions to your insurance provider…
- Do you have mental health benefits? If so, what are they?
- NOTE- your benefits may be more flexible than you think (ex. 30 hospital days equates to 60 residential days, meaning that the total is 120 treatment services)
- What are the billing processes?
- Which covered treatments are funded through the health section of your plan? Try to keep medical services funded through the medical section of your plan (ex. If psychiatrist is providing medication management services, utilize medical coverage because there is lower co-pay and services will not be as limited)
- Which are funded through mental health services?
IMPORTANT: If you have difficulty understanding your benefits, call the number on the back of your card and talk with the customer service representative. If you do understand the benefits, ask for an Individual Case Manager so that you can have a name and contanct information for any further questions.
Mental health parity laws by state…
The Mental Health Parity Act (MHPA), signed into law on September 26, 1996, requires that annual or lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer offering coverage in connection with a group health plan.
Review level of care guidelines…
Newest guidelines supersede previous guidelines even if you are trying to get coverage or payment for treatment that originally fell under old guidelines.
American Psychiatric Association (APA)
American Academy of Pediatrics
Society for Adolescent Medicine
IMPORTANT: Ask the insurance representatives if he or she can review the guidelines that the company uses. They may be resistant to giving you these, but you have a right to know them and they must provide them to you.
Review your child’s needs…
Your child does not need to “fail” at a lower level of care to receive the appropriate level of care
- Meet with the treatment team to establish your child’s current treatment issues and to determine the appropriate level of care based on the above practice guidelines
- Have at your disposal the current guidelines that are appropriate for your child (see above for links) and share a copy with your insurance company and the treatment team
- Request that your child’s current level of care be based on the accepted guidelines, and if the request is denied, insist that your insurance company take full responsibility (in writing) for your child’s life, noting that they are disagreeing with the qualified experts in the field and the approved guidelines
- Keep in mind that a more intensive level of care might be necessary due to distance between your home and the services available
IMPORTANT: Before you contact the insurance company for services, make you you fully understand your policy.
Contacting the insurance company for services…
- Thank and compliment when possible; you’re more likely to receive friendly service if you are nice as well
- Keep written records of all communications with your insurance company, keep all explanation of benefits you receive, and write everything down along with the name of the person you spoke to, the time and date, what was discussed, and any advice or decisions that were made
- Make follow-up phone calls to your requests so you are not forgotten
- Send important letters that you want noticed or responded to via certified mail to ensure they can be tracked and signed for at the recipient location
- Don’t assume one department knows what the others are doing; inform all the departments, including health, mental health, enrollment, etc.
- Don’t panic; it is possible that a denial can be an automatic computer generated response that requires a “human override,” so continue to pursue
- The insurance company only knows what you and the treating professionals tell them; make sure they have all necessary information to make decisions that will be of the most benefit to you or your loved one
- Don’t be afraid to point out that eating disorders are both medical and psychological illnesses
If your child is already in treatment…
- Ask for a list of professional, qualified experts and facilities utilized by your insurance company for this illness at this level of care
- Ask for a copy of the guidelines your insurance company uses to determine level of care
- Share a copy of the guidelines you have utilized with your treatment team to make recommendations to your insurance company
- Review your child’s current level of needs based on these guidelines with your insurance company, then submit documentation requesting services
What to do if treatment is denied…
- Learn the “rules” for filing appeals with your insurance company
- Call the company and ask for a detailed description of the appeals process and who makes the decisions within the company
- Submit all forms and documentation; write a clear, concise cover letter that is brief, states your expectations, and sets a timeline for resolution of an issue
- Be clear about what you are asking for; if residential treatment is indicated, that is what you must ask for
- Collect data that will corroborate your request by asking your doctor, psychologist, dietician, and other treatment professionals to write letters of support with their arguments for the level of care they are recommending
- Include medical test results, facts, research and any other information that states your case
- Send all of the information you gather to your insurance company’s customer representative and review board
Information taken from NEDA, the National Eating Disorders Association