As insurance companies continue to use managed care techniques such as utilization review—where your insurance company works with your provider to determine if a treatment plan is necessary for your well being -- to control health and mental health expenses, consumers must become increasingly knowledgeable of the utilization review and appeals processes in order to effectively fight for the treatment they need and deserve. By following the steps listed below, consumers, family members, and advocates will increase the likelihood that necessary treatment is provided.
I. To Help Ensure That Treatment Is Approved
- Review your health plan’s utilization review and appeals procedures as soon as possible.
- Make any calls that your insurance company requires before you seek treatment and be sure your provider does the same. This is part of the "pre-authorization" process.
- To the extent that you are comfortable doing so, provide consent for your provider to release your medical information to the insurance company.
II. To Appeal a Treatment Denial
- Insist that your provider help you to appeal.
- Make sure your provider requests a special, expedited appeal for emergencies.
- Confirm with your insurance company that your services will be covered during your appeal.
- Request, or have your provider request, written notification of the reasons for denial.
- Make sure that you and your provider meet all deadlines.
- If you are on Medicaid, request a "state fair hearing" from your Medicaid office.
III. If Your Appeal Fails
- Appeal again! Most insurance companies have several levels of appeal.
- Request an appeal review by someone who is not employed by the insurance company.
- Seek help from an ombudsman program or your employer’s Human Resources department, if applicable.
Make alternative treatment plans in case additional appeals are not successful.