Take Action

Consumers and providers have increased protections because of the new Federal Parity Law, but it is up to all of us to take advantage of these rights and hold insurers accountable. If you, a loved one, or client are not receiving care that is needed, Take Action and file an appeal with your insurer or a complaint with the proper government agency. You can do this on your own following the steps below, or Contact Us for help.

Step 1: Know Your Plan

Your rights and benefits depend on how you are insured. If you get insurance through your employer, the laws governing your plan differ depending on whether your employer is large (51+ employees) or small (2-50 employees). Rules are different for individual policies and government plans. If you don’t know your plan type and get insurance through your employer, ask your benefits representative, usually the Human Resources or Personnel departments. You can also call the number on your insurance card.

What Does Self Insured Mean? To further complicate things, if you are insured by a large employer, there’s one more hoop to go through. You need to know whether your employer is “self insured” or not. Normally an employer buys insurance and pays a monthly premium for your coverage (you may pay a portion of that monthly fee through payroll deduction). The insurance company pays all of the medical bills for insured employees. If employees have a large amount of medical bills that exceed the total of the monthly premiums collected by the insurance company, the insurer is “at risk” and payss the difference. Some large companies prefer to hold the risk themselves and contract with insurance companies only to administer their insurance plan (i.e. handling enrollment and paying health care providers for services rendered, with the company’s money). This is referred to as a self insured plan. Your benefits representative will also know if your plan is self or fully insured.

Read more about different types of insurance plans

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Step 2: Obtain Written Reason for Denial

If you have been denied coverage or reimbursement for treatment, your insurer must provide you and/or your provider with a reason for this denial in writing. If you have not received this document, you have the right to request it from your insurer, free of charge and in a timely manner. You can call your insurer with your member number and the date of treatment request to get this document.

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Step 3: Ask for Help

Your provider can help with appeals to your insurer. He or she is often the first to receive billing information, including denials from insurers, and may have information you need in order to continue the process. Sometimes your provider may have already filed an appeal on your behalf. If you decide to file the appeal alone, you should notify your provider because the insurer may need to speak with him or her.

For help in filing an appeal

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Step 4: Gather Materials

The items listed below may be useful if you continue through the appeal process. Collecting documents and taking notes can be tedious but are often very important to winning an appeal.

Explanation of Benefits Booklet
This is the book you should have received when you first got your health insurance information. It may outline the appeals process. If you don’t have a copy, you can request one from your insurance company or from your insurance representative at your employer. It can sometimes be found online.

Reason for Denial of Treatment or Reimbursement
This must be presented to you timely and free of charge.

Definition of Medically Necessary
The insurance company must provide you with written criteria they use to determine whether your treatment was medically necessary and an explanation of how they applied this criteria.

Letter Explaining Necessity of Prescribed Treatment
Your provider will give you a letter describing why your treatment was necessary.

Medical Bills and Tracking of Visits
Keep copies of bills and records of visits for treatment. When in doubt keep any documents you receive about your treatment until the appeal and complaint process is complete.

Good Notes
Document all calls and conversations you have regarding your appeal. Keep track of names and dates of all conversations.

Understanding the Process
If you are unsure of the appeal process, check your benefits book, ask your insurance company, or seek help from your benefits representative at your employer. You can also Contact Us for help

Download the following sample letters to use in requesting these documents.
Note Taking Form
Appeal of Denial of Treatments

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Step 5: File An Appeal With Your Insurer

Make sure to do this within the time allotted. If you are unsure of the process or deadlines, call your insurer or your benefits representative at your employer or Contact Us

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Step 6: Exhaust Internal Appeals Processes

Different insurance companies may have different internal appeal processes. Be sure to follow this process and meet all required deadlines. Often if the first appeal is denied, the next level of appeal will be outlined in the denial letter with deadlines and contact information.

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Step 7: File a Complaint

After you have exhausted internal appeals with your insurer, you can ask for an external review of the denial. This is done by filing a complaint with the proper government agency. In the complaint be sure to reference the federal parity law and any potential violations. Most complaints are filed with the Maryland Insurance Administration (MIA). Exceptions are the following:

  • Complaints for large employer, self insured plans and complaints for state and local government plans are filed with the US Department of Labor
  • Complaints for federal government plans are filed with US Office of Personnel Management

If you choose to file a complaint, please consider working with the Maryland Parity Project to do so or send us a copy of the filed complaint.

These sample letters may be useful in the appeal process.
Note Taking Form
Appeal of Denial of Treatments

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Step 8: Ask for a Hearing

If your complaint is under the jurisdiction of the Maryland Insurance Administration, and it upholds the decision of the insurer, you are entitled to a hearing. The details and timelines of how to request this will be outlined in the MIA decision letter.

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Step Up: Advocate for Parity

If you received no satisfactory recourse, or you simply felt the process was too difficult, consider working for better mental health laws and oversight. Contact Us and/or write a letter to your Federal or State elected officials.

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