It is generally a good idea to seek authorization first, regardless of whether you are in PPO or an HMO, so that there is a record that you made a formal attempt to go through the appropriate channels to secure coverage. If you are in an HMO, this usually means going through your primary care provider (PCP) for “medical services” like speech and occupational therapy. In HMO’s, sometimes the primary doctor may need to provide a written pre-service request.
Typically for outpatient mental or behavioral health therapy, you can refer yourself by calling the behavioral health number on the back of your member id card. Tell them that you will need a therapist skilled in treating the condition that you or your loved one has. This is especially important if your child has autism or a developmental disability, as not all licensed providers have expertise in this area.
Don't assume that just because someone has a speech therapy license, for example, s/he has experience working with children with autism. A speech therapist who works primarily helping elderly people to swallow after stroke, for example, would not be the appropriate therapist to teach language pragmatics or who/what/where questions to a preschooler with few words. When you call the plan to get names of appropriate therapists, request a tracking number, write down the name of who you spoke with and the date of each call. Some plans will allow you to communicate with customer service representatives online via chat, and submit documents/claims online. If you do this, print the online chat and save it, so that you have a written record of what you were told.
If you are in a situation where you are laying out the money (common in PPO's), send in claims to the address on the back of your insurance card, via certified mail (save the receipt, as you can track the document and prove that it was received) or call the insurance company for a fax number. Follow up all claim submissions with a phone call a week or so later, to confirm that they received the claims. Clients frequently report that the insurance companies tell them that they never received documents that were previously sent.
Many health plans require prior authorization for certain services, such as:
This requirement is usually listed in the plan manual (even the short summary of benefits) and often applies to those in PPOs as well. Some plans will charge a penalty for failing to obtain prior authorization, and some say they won’t pay at all. If you see a non-network provider for the above mentioned services, often the onus is on the member to obtain this authorization for non-network care. It can be further complicated by the fact that many plans won’t issue approvals without speaking with the facility or the provider. As a member, we encourage you to call and advise the plan, note the date, who you spoke with, be clear that you are requesting prior authorization, and get a tracking number. Encourage your provide or facility to follow through. If they do not work with insurance, we can obtain permission to call in on their behalf. Many state regulators will not allow a health plan to deny for this reason, and it is usually not a deal breaker if you don’t obtain it. However, if you know in advance, it’s a good idea to call.
If your provider or facility works in-network with health plans, they usually take full responsibility for obtaining prior and ongoing authorizations, and submitting claims. Cost sharing is much less as well. You will get the most bang for your buck if you stay within the network, but for a variety of reasons, that is often not possible.
A SPECIAL NOTE ABOUT KAISER
Many of our Kaiser families have attempted to obtain mental health services from Kaiser. They may be working with a Kaiser psychiatrist or therapist that has either not agreed that they needed more intensive treatment, tried to refer them to a facility that the patient felt was inappropriate, or they have been referred to intensive services by a non-Kaiser specialist. Regardless of the scenario, when requesting any of the above-mentioned treatments from Kaiser, if the Kaiser physicians are not approving your requests, it is important to remember that you need to go back and make a formal request to the member services department before you start treatment. We are not sharing this information to single out Kaiser, we are letting you know this because we have seen too many families be denied the opportunity to appeal because they failed to take this step prior to starting services.
WHAT TO DO IF THE PLAN DOES NOT HAVE PROVIDERS THAT CAN TREAT YOU
Usually HMOs and PPOs have lists of in-network providers in your area. Go to the plan website or contact the plan for lists of appropriate providers.
For mental health services in CA (fully funded plans), the plan cannot require you to drive more than 15 miles from your home. For medical services, the limit is 30 miles. You can argue that speech and OT therapies are treatments for your child’s mental health condition. You can also argue that your child with autism can't sit in a car for 30 miles on a weekly basis, if that is the case. Medi-Cal has similar limits, but it varies by county, -- if you live in a rural county, they may expect you to drive further.
Each state has been charged with developing their own network adequacy standards, based on a model developed by the National Association of Insurance Commissioners (NAIC). These standards typically apply to health plans purchased on the exchange, though many states require them for all plans that they regulate. For self-funded plans, check your plan manual to see if this issue is addressed.
Call the in-plan therapists, verify that they have experience treating people with autism or the condition that your child needs. If they want to put you on a waiting list, allow them to, but you can also try to find a provider out of the network that is willing to work with insurance. If none of the providers on the list have experience or availability, contact the health plan and tell them that their network is insufficient and that you will need a single case agreement to use your own provider, if you have one. The plan is obliged to pay for this, while you pay co-pays and deductibles at the in-network rate (this applies for PPOs too). Get names of qualified providers from other parents, online support groups or physicians knowledgeable about your condition. If the plan gives you a hard time about this, contact your regulator and report that the network is insufficient and that the plan is not responding adequately.
Online Users Groups The following online user’s groups are run by loved ones of people with autism in CA. They are an excellent source to find names of good autism providers in a given area within California, or to ask questions about insurance: https://groups.yahoo.com/neo/groups/ASDinsurancehelp/info
And for Kaiser: https://groups.yahoo.com/neo/groups/Kaiserspectrumkids/info
In some areas, support groups organized by the local affiliates of the National Autism Society or the National Association for Mental Illness (NAMI) may be able to offer guidance.
PPOS AND LOW RATES OF REIMBURSEMENT
Frequently, clients in PPOs report that they are reimbursed at very low rates when they see out-of-network providers. For instance, on a 50-minute visit where the psychologist charges $150, the plan is supposed to pay 80% of what they deem to be usual/reasonable and customary for a given geographic area. Sometimes they determine that $50 is reasonable and customary (for a PhD level psychologist in a high rent area it is not!) and will pay 80% of the $50, which comes out to only $40. The Fair Health website was developed both to help insurers determine reasonable and customary rates for specific procedures, and to help consumers obtain unbiased information on what they should be reimbursed for out of network procedures. It was developed in response to a lawsuit. We encourage you to key in what you should be paid, and if it does not match or come close to what you are getting reimbursed, you can put together an appeal letter. Legally, the plan is supposed to disclose the methodology that they used to determine how they arrived at this amount. Sometimes it is available in the plan manual, but if it is not, you can request this information. As a general matter, it is a good idea to carefully check the explanation of benefits statements and make sure that the plan is paying according to the contract.
If you have a self-insured plan through your employer, you can also let your plan administrator or human resources director know that the plan that they are contracting with is not paying market rates. Large employers often have the power to speak up and make an impact.
FILING A GRIEVANCE OR APPEAL WITH YOUR HEALTH PLAN
If you are dissatisfied with how your case has been handled, but you have not received a formal denial for services, you can file a complaint or grievance with your health plan. If you have received a denial for services, either in the form or an unpaid or underpaid explanation of benefits (EOB) statement, or an actual letter, you can file an appeal.
Denials typically fall into two categories:
- Medical Necessity: These denials usually involve a dispute about whether or not a particular treatment is needed. It can also involve disputes about how much treatment you need, the type of treatment, how long the treatment should last, and where and how it should be delivered. If not resolved by the health plan during the internal appeal phase, these types of disputes usually go on to an external appeal, where a medical expert from an independent reviewing agency reviews all documents and determines whether or not the service in dispute is needed. Many have voiced concerns recently that external reviewing agencies may not be truly independent of health plans. A recent CA court ruling allowed a reviewing agency to be named as a co-defendant in a medical necessity dispute.
- Administrative: These disputes are basically about everything other than medical necessity: denials alleging that a service is not covered, unable to access treatment; insufficiency of the network, failure to pre-authorize, underpayment of claims, and a variety of other things. For these types of denials, you may need help from your state regulator if fully funded, or the Department of Labor (Employments Benefits Security Administration- EBSA) or your employer, if self-funded.
Legally, when a plan denies services, they are obliged to identify the claim, including date of service and provider, amount billed, and describe the reason/s for denial in writing. If something is not medically necessary, they have to tell you why. They are supposed to make guidelines used available to you on request. REQUEST THEM!! They are also supposed to describe any further documents needed to finalize the claim, advise you of your rights to appeal, notify you of consumer assistance, and notify you that culturally appropriate information and translation is available if needed. For details of what needs to be included, click here.
If care is being discontinued that had been previously approved, the plan is supposed to allow you an expedited appeal and get back to you within 72 hours. They are also supposed to allow you sufficient advance notice so that you have ample time to appeal. Below is a little known section in the ACA which requires that plans provide advance notice for denial or provide continued coverage pending the outcome of an appeal: CFR: Section 147.136 F (2) (iii) Requirement to provide continued coverage pending the outcome of an appeal. A plan and issuer subject to the requirements of this paragraph (b)(2) are required to provide continued coverage pending the outcome of an appeal. For this purpose, the plan and issuer must comply with the requirements of 29 CFR 2560.503-1(f)(2)(ii), which generally provides that benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review.
When we write appeals on behalf of claimants, we put a great deal of thought and time into constructing a cover letter. We encourage you to include the following information with an appeal (and later, with requests for either external review or assistance from the regulator):
You are typically expected to appeal internally within health plan first, unless you are appealing on an expedited basis (see section below on Requesting Expedited Status), and then you can complain within the plan and to the regulator and/or external reviewer at the same time. You complain to the regulator for administrative types of denials, and to some regulators, for medical disputes. In many states and in self-funded plans, you send the request for external review to the health plan, and they will forward the request on to the external reviewing agency. Instructions should be provided in the denial letter.
You can use the same cover letter and the same packet of information that you already submitted for the internal appeal, with minor modifications:
- You will want to include updates on your health status if there have been any changes (or new reports).
- You may want to directly address how the plan responded to your initial appeal or second appeal, and refute it if there are incorrect facts or explain how you disagree with how they reached their conclusion.
CA has two state regulators: The Department of Managed Health Care (DMHC) which generally regulates all HMOs (Health Maintenance Organizations), most exchange plans, and most of the Blues (formerly, Blue Cross of California, now called "Anthem", and Blue Shield of California), and Medi-Cal Managed Care plans in non COHS counties; and The California Department of Insurance, which generally regulates all other PPOs, traditional indemnity plans, POS (point-of-service) plans, and Blue Shield and Anthem Life and Health Insurance. If your insurance is issued in a state that differs from where you live, read the evidence of coverage manual carefully, -- it is likely regulated by the state where it was issued.
According the EBSA publication “Filing A Claim for your Health Benefits,” health plans have 3 days to respond to urgent requests, 15 days to respond to a pre-service, and 30 days to respond to a post-service claim request. If they deny and you submit an appeal, they have 3 days to respond to an urgent appeal, 30 days to respond to a pre-service appeal, and up to 60 days to respond to a post-service appeal (many health plans and states require no more than 30 days). Some plans require a two step appeal process in order to “exhaust” your appeals, and others only require one. This information should be in your plan manual. If you have a fully funded plan, check with your state regulator, as state requirements may be more stringent.
We believe that once you have exhausted your in-plan appeal, it is a good idea to consult with an attorney to obtain guidance on whether it is better to proceed with external review or civil litigation. We have a network of attorneys that we refer our clients to, if we are unsuccessful in overturning their cases on appeal. Many will take cases on contingency and are successful in recovering their attorney fees. The litigation process often ends in settlement but can take more than a year.
What is an independent medical review? An independent medical review is a review by a medical expert or team of experts when there is a dispute about whether the treatment is needed medically or if the health plan alleges that that the treatment is experimental or unproven. What happens is that an independent reviewing agency staffed by a medical specialist in the disputed area is called on to evaluate the medical literature, review the case on paper, and decide whether there is adequate evidence in the medical literature to support the treatment for a specific condition, given the specifics of the case.
If you were denied treatment for medical reasons (this includes “experimental”), or if there were procedural violations in how your case was handled, you should be entitled to an external review. These reviews are paid for by the employer (self-funded plan) or the health plan (fully funded plans). Rates of overturn vary by state, and also by type of treatment that you are disputing.
If the issue is a question of medical necessity, generally health plans send the case to one expert; if the health plan claims the treatment is experimental, they may send it to a three-person panel. Sometimes the reviewing agency needs additional information in order to send the file out to external review, however, they should inform you of this in a timely manner. Often the reviewing agency will reach out after they have received your request, -- if they do, it is a good idea to verify that they have the correct number of pages, as we know of situations where the health plan did not turn over the entire file.
Both CA regulators adopted emergency regulations in which they required health plans under their jurisdiction to provide services to children with ASD because they found that “Delays and/or interruptions in behavioral health treatment services for children with PDD and Autism can result in permanently impaired development and increased potential for irreparable disability and/or substantial financial harm.” If you are in a CA regulated plan and are experiencing delays in getting, continuing, or receiving payment for services ASD services, you may cite this regulation and request that your case be handled on an expedited basis.
If care was approved and is now being terminated, or the amount/frequency of care is being modified, you may also request that your case be appealed and sent for external review on an expedited basis.
For other circumstances, check your plan manual to see how they define types of situations which qualify for expedited status.
If you can’t get autism or mental health coverage through your self-insured employer, you can purchase an individual plan for your child through a licensed insurance broker or through the state health exchange. You cannot be charged more for a pre-existing condition.
For a list of marketplaces by state, click here. Usually the marketplaces open in November for the following January, but you can also access services during the year if you have experienced a life-changing event, including a move to another state, loss of job, birth of a child.
In CA, you can obtain information on purchasing a plan through Covered CA, the CA exchange. Below are names and contact information for CA licensed brokers that we have referred families to and are familiar with some of the issues that our families face: Ethelynn Bates, T: (800) 748-4327, e-mail: firstname.lastname@example.org Phyllis Hyde, T: (310) 933-0328, e-mail: email@example.com Kelley Jensen, T: (408) 350-5763, e-mail: firstname.lastname@example.org