Many insurance policies create challenges and confusion for patients who are seeking insurance coverage for the treatment of an eating disorder. Despite your frustration and surprise with a denial or termination of treatment, there are steps you can take for yourself or your family member who is suffering from an eating disorder. Donít give up! Use denials as an opportunity to educate your insurance company about the necessity of appropriate treatment and the devastating consequences of inadequate coverage. Often, your persistence will result in a favorable outcome. Start by gathering the initial information described below, then use the links on the left to take the next steps.
Understand your insurance policy
- Read the insurance policy/summary plan description (SPD) to determine the medical and mental health coverage provided by your policy.
- Is your plan covered by ERISA? ERISA is a federal law that controls disputes with most employer-based insurance providers. Click HERE for more information on your rights under ERISA.
- 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 are you in the process?
- Did you attempt to initiate a pre-authorization process?
- Have you received an oral or written denial of care? Date?
- Have you filed a formal written or oral appeal? Date?
- Has your appeal been formally denied?
- Have you investigated or filed a secondary appeal?
- Have you exhausted the appeals process?