Helping People Whose Benefits are Denied | MAMH

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Helping People Whose Benefits are Denied

WHAT TO DO IF A BENEFIT IS DENIED

If you have been denied coverage for treatment of a mental health or substance use condition, you may appeal. The written notice from the insurer denying coverage should explain the reason for the denial and describe your appeal rights.

The first step is an appeal to the insurance plan. This must be done within 180 days of the denial. The appeal letter should describe why the plan is wrong to deny the coverage and should be supported by medical records and a letter of support from the treating provider. Health Law Advocates has a sample appeal letter in its Mental Health Parity Toolkit: 2017 Edition.

The plan must decide the appeal and issue a written decision within 30 days. There are provisions for an urgent appeal and an expedited decision.

If the appeal is denied, you may, in some cases, seek “external review” or go to court. External review is voluntary and is not available in all cases. For some plans, external review is final and you may be prevented from going to court. Therefore, it is very important to make this decision in consultation with an attorney, before seeking external review.

External appeals must be filed within four months of the denial of the internal appeal.

Where you file depends on the type of plan. Massachusetts residents who are not in self-insured plans often are required to file with the Health Policy Commission’s Office of Patient Protection.

If you decide not to appeal, or in addition to appealing, you can complain to government agencies about what you think may be parity violations. Here are some of the agencies with jurisdiction:

Massachusetts Attorney General
Massachusetts Department of Labor
Massachusetts Division of Insurance
MassHealth Appeals – Fair Hearings (Phone: 1-800-655-0338)

For legal assistance, please contact:
Disability Law Center
Health Law Advocates
MassLegalHelp (online assistance and information)
Mental Health Legal Advisors Committee