Navigating Insurance Coverage for Mental Health and Substance Use Treatment
This is Francis. Francis is a trained peer recovery coach. As a peer recovery coach, he helps people who need substance use disorder or mental health services.
Rose is an injured athlete who became dependent upon pain medications prescribed to her by her doctor. Rose tells Francis she needs help now. Francis gives her the Resource Guide for Addiction and Mental Health Care Consumers. Francis tells Rose she should call the crisis line or the suicide line if it is an emergency. The crisis line is 1-844-711-HELP.
Rose does not feel she is in crisis but knows she needs treatment now. Rose is unsure where to go for treatment, so she opens the Resource Guide. She learns she can get help finding a provider by first calling her insurance company and then looking on the New Hampshire Treatment Locator site at www.nhtreatment.org.
Rose calls her insurance company and asks for the names and telephone numbers of qualified providers who are in network. She also asks if her insurance company requires any pre-authorizations before she can receive treatment. The insurance company tells Rose that she needs to have an evaluation at her local health center before she can begin treatment.
Francis drives Rose to the local center for her evaluation. Rose receives an evaluation and is connected to the services she needs.
Aster’s Story: Getting Coverage After Losing a Job
While Rose is being evaluated, Francis meets Aster in the waiting room of the health center and identifies himself as a peer recovery coach. Aster tells Francis he recently lost his job and his coverage. He has been struggling with severe depression, chronic alcohol use, and withdrawal symptoms.
Aster is worried he will not get help because he does not have insurance. Francis suggests Aster ask if there are trained staff at the health center who can help figure out what insurance might be available to him. Francis also recommends Aster look at other options on www.healthcare.gov. Aster enrolls in an insurance plan and is approved for an inpatient residential treatment program.
When Insurance Denies Your Treatment
Aster successfully completes his inpatient program and is on the road to recovery. All of his providers recommend outpatient services as the next step. Aster is upset to learn his treatment is denied by his health insurance company. This means his insurance company will not pay for the ongoing treatment he needs to maintain recovery.
Aster reaches out to Francis, who tells Aster not to give up and not to take “no” for an answer. Aster has a right to fair insurance coverage. By using the Resource Guide, Aster can work with his provider to navigate the appeal process so that he can access the treatment he needs.
Francis recommends that Aster call his insurance company and ask the following questions:
Why was I denied?
How do I appeal?
How much time do I have to appeal?
Can I have a copy of my denial letter?
Understanding the Types of Appeals
Francis explains there are several types of appeals, also known as reviews.
Internal Appeal: A review conducted by your insurance company.
External Appeal: A review conducted through the New Hampshire Insurance Department.
Both types of appeals can be expedited.
Filing an Expedited Appeal
Aster knows he wants to appeal but needs a decision quickly. Aster’s provider believes he needs help now and is at risk for relapse without the outpatient treatment.
Francis explains to Aster that he can ask for an appeal for any reason, and can also ask for it to be expedited. With an expedited appeal, a decision must be made within 72 hours. Francis encourages Aster to discuss the denial with his provider. For an expedited appeal, his provider must certify that his life and health are in danger if he does not stay in the recommended outpatient treatment.
Because Aster needs treatment right away, Aster and his provider use the Resource Guide to find out more about the appeal process. Aster and his provider call the New Hampshire Insurance Department to find out how to quickly file an expedited appeal and gather the required appeal documents at 1-800-852-3416.
They call to inform the insurance company that Aster is seeking an expedited appeal immediately. The provider speaks with the insurance company and explains the medical reasons for the treatment. Aster and his provider file documents as instructed.
Although Aster was worried about his expedited review, his insurance company decided to cover the outpatient treatment. With the help of his provider, he was able to continue receiving the services he needed to maintain his recovery.
How to File a Standard Internal Appeal
Continuing his work as a peer recovery coach, Francis educates groups about all types of appeals. He outlines the steps to follow to file an internal appeal when you are not in an emergency and do not need an expedited review.
Your provider should call the insurance company to try to clear up any misunderstandings about your need for treatment or services.
Write an internal appeal request letter by filling out Form 2 located in the Resource Guide.
Include an explanation by your provider about why you need treatment and send it in.
You should hear back from your insurance company within 30 days.
Francis encourages people not to give up.
How to File an External Appeal
If an internal review is denied, follow these steps:
Follow the detailed instructions in the Resource Guide to successfully file an external appeal.
File an external appeal with the New Hampshire Insurance Department within 180 days of the date of your denial letter.
Make sure you have your denial letter from your health insurance company.
Get help from the New Hampshire Insurance Department Consumer Hotline, your provider, or an advocate if you need help with your appeal.
Conclusion
Help is available so that you can receive the healthcare coverage you are entitled to in order to continue on your path to treatment and recovery. Do not give up. You have a right to fair insurance coverage, and there are people and resources ready to help you navigate the process.
Q: What should I do if I am in a mental health or substance use crisis?
A: Call the crisis line or the suicide line immediately. The crisis line number is 1-844-711-HELP.
Q: How do I find a treatment provider?
A: Call your insurance company to ask for in-network providers, or use the New Hampshire Treatment Locator at www.nhtreatment.org.
Q: What if I do not have insurance?
A: Ask health center staff if they can help you find coverage options, or visit www.healthcare.gov to explore available insurance plans.
Q: What should I do if my insurance company denies my treatment?
A: Do not give up. Call your insurance company and ask why you were denied, how to appeal, how much time you have to appeal, and request a copy of your denial letter.
Q: What is the difference between an internal and external appeal?
A: An internal appeal is a review conducted by your own insurance company. An external appeal is an independent review conducted through the New Hampshire Insurance Department.
Q: How quickly is a decision made on an expedited appeal?
A: A decision must be made within 72 hours for an expedited appeal.
Q: How long do I have to file an external appeal?
A: You have 180 days from the date of your denial letter to file an external appeal with the New Hampshire Insurance Department.
Q: Who can help me with the appeal process?
A: You can get help from the New Hampshire Insurance Department Consumer Hotline at 1-800-852-3416, your treatment provider, or an advocate.
