State and Federal Mental Health Parity laws have given many behavioral health treatment providers hope regarding mental health care reimbursement.
However, a Governmental Accounting Office report studied the effect of mental parity mandates and found that insurance carriers often modify policies to allow more equal coverage for mental health treatment but offset parity costs through higher deductibles, copays, treatment caps and other subtle limitations to coverage. Further, most parity laws specifically state that medical necessity policy provisions still apply to coverage availability, thus leaving insurance carriers with this additional avenue of cost control.
The result is a confusing array of mental health limitations and clinical guidelines which can be difficult to assess for health parity compliance.
Appeal Solutions has developed a number of letters which cite state and federal mental health parity requirements. These letters can be used to demand disclosure of the benefit calculation to determine compliance with potentially applicable provisions. As a general rule, mental health claim appeals must often address the following key issues:
(1) Disclosure Request – Mental health care appeals should demand full disclosure of denial details. Denials can be vague. Even clearly stated denials such as “denied due to lack of medical necessity” does not provide important information such as the behavioral health criteria used to assess treatment. Therefore, a Level I appeal should request the specific written limitation, exclusion or internal guideline which applies to the denial. Further, if the appeal is related to poor reimbursement, your letter should request disclosure of the methodology used to calculate the payment.
(2) Compliance Review – Mental health claim appeals should cite either the U.S. Mental Parity Act or your state’s mental health coverage requirements. This requires being well educated on both state and federal requirements and how these requirements affect copays, coverage caps and medical necessity review. Some state mental health parity laws specifically apply to out-of-network care while others reference only in-network care.
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