I think I’ve experienced a parity violation, now what?
There are multiple steps you can take to challenge your denial of coverage. It is important that you go through these steps in the right order and have help from someone who understands the process, if possible.
Before beginning the process, contact your provider
Your provider should be able to help determine the reason why your treatment has been denied, and can submit a letter to your insurer detailing why your treatment is medically necessary, which is an important part of successful appeals.
What will I need for the appeals process?
You will need several things to go through the appeals process:
- Any official denial letter from your insurer- in denials based on medical necessity, your insurance plan is required by law to send this to you
- Any explanation of benefits
form that explains the treatment in question
- Sometimes, insurers are not obligated to send you a denial letter, or a potential violation will occur without treatment being denied. In either of these cases, this form will have the information needed to determine if a violation has occurred.
- The criteria your insurer uses to determine what types of treatment are medically necessary for both behavioral health treatment and other types of medical care
- All records and bills from the treatment
Who do I file an appeal with?
The first level of appeal is an internal appeal with your insurance company. You may file an appeal claiming your insurance plan is violating parity laws by denying treatment, or an appeal addressing when your insurer denies coverage because it does not believe the care is medically necessary.
These medical necessity appeals are usually the most common appeals that are filed, but you should talk with your provider about which appeal seems most fitting. Multiple types of appeals can be filed at the same time, which can be helpful because insurance plans must provide more information to you and your provider under a parity appeal than a medical necessity appeal.
How long will an internal appeal take?
Generally, your insurance company will respond to your appeal within 30 days. However, if the denial of care results in an emergency situation, you can file an expedited appeal, which your insurer must to respond to within 72 hours.
What if my internal appeal is denied?
If your insurance plan still denies care after an internal appeal, you may be able to file an external appeal, which is reviewed by an independent review organization. This type of appeal must generally be filed within 4 months of the denied internal appeal, and also has an option for expedited appeal.
What if my external appeal is denied as well?
If you exhaust all of your appeals options with your insurer and care is still denied, you may file a formal grievance with the appropriate state or federal agency responsible for overseeing your insurance plan. If you choose to file a grievance, contact state officials or advocates to determine who your appeal should be filed with. A list of state agencies and advocates can be found here.
Additionally, you may choose to pursue legal action against your insurance plan for improper denial of treatment.
How much will all of this cost?
Insurance plans cannot charge you to file an internal appeal, and only in rare cases will an external appeal cost money. Filing appeals with state or federal regulators also does not cost money. However, if the appeals process is not successful and you or your provider feel that additional legal action is necessary, there will likely be legal fees associated with using a lawyer.