Many insurance policies create challenges and confusion for patients who are seeking insurance coverage for the treatment of an eating disorder. When a patient or family is notified of a denial or termination of treatment, be proactive in assisting the family in appealing the decision. Use denials as an opportunity to educate your insurance company about the necessity of appropriate treatment and the devastating consequences when treatment is unavailable. With guidance and support, many families are successful in obtaining needed services via appeal, waiver, or negotiation, even in the case of plans with limited coverage. Often, your help and persistence will result in a favorable outcome.
Gathering Initial Information
Understand your patient’s insurance policy
- Read the insurance policy/summary plan description (SPD) to determine the medical and mental health coverage provided by the policy.
- Whenever possible, make treatment recommendations that are within the bounds of your patient’s plan’s coverage.
- If appropriate coverage is being denied, identify the written and oral appeals procedures specified by the plan.
Identify the specific reason for the denial
- Denial because treatment is not "medical"
- Denial because patient does not meet specific coverage criteria
- Denial because a young patient does not meet specific coverage criteria
- Denial because the requested facility or specialist is out of network
- Denial of comprehensive care because it is "not covered"
- Denial of your request for day treatment or residential care
- Denial because patient has met coverage limits or because medical or mental health benefits have been exhausted
- Denial of continuing care
Where is your patient in the process?
- Did the patient attempt to initiate a pre-authorization process?
- Has the patient received an oral or written denial of care? Date?
- Has the patient filed a formal written or oral appeal? Date?
- Has the patient's appeal been formally denied?
- Has the patient investigated or filed a secondary appeal?
- Has the patient exhausted the appeals process?