Appealing a Rehab Insurance Denial

A denial can arrive while the person you love is still in the building, or still sick at home, and the letter can feel like the last word. It is a document with a deadline. HealthCare.gov says that if an insurer refuses to pay a claim or ends coverage, you have the right to appeal and to have a third party review the decision. The insurer has to tell you why it denied the claim or ended coverage, and how you can dispute that decision.

If withdrawal, an overdose, or trouble breathing is happening now, call 911. For a mental health crisis, call or text 988. The appeal clocks below are for after that emergency is handled.

Those sentences describe the process HealthCare.gov publishes for health plan decisions. They are not a single clock for every card in the country. Medicare.gov says Original Medicare, Medicare Advantage, and Medicare drug plans have their own appeal paths, and that the process varies by the kind of coverage you have. If the denial is from Medicare, follow the instructions in that decision letter. Medicaid appeals are set by the state program. Read the letter in front of you before you borrow a timeline from a different kind of plan.

The page on rehab cost with insurance explains deductibles, networks, and prior authorization. The steps here start after a no.

The two reviews HealthCare.gov describes

HealthCare.gov describes an internal appeal and an external review.

An internal appeal is your request that the insurance company conduct a full and fair review of its decision. If the case is urgent, the company must speed the process up.

An external review means an independent third party reviews the dispute. HealthCare.gov says the insurance company no longer gets the final say, and that the insurer is required by law to accept the external reviewer's decision.

You can appeal a denial when the plan will not provide or pay some or all of the cost of services you believe should be covered. HealthCare.gov lists reasons that include: the benefit is not offered; the plan says the problem began before you joined; the provider is out of network; the service is "not medically necessary"; the service is called experimental or investigational; you are no longer enrolled; or the plan is revoking coverage back to enrollment because it says you gave false or incomplete information.

Deadlines on that page

HealthCare.gov separates the plan's first decision from your appeal.

For the first decision, it says the insurer must notify you in writing and explain why within 15 days if you are seeking prior authorization, within 30 days for medical services already received, and within 72 hours for urgent care cases.

You must file the internal appeal within 180 days, which the page also calls six months, of receiving notice that the claim was denied. The internal appeal must be completed within 30 days if the appeal is for a service you have not received yet, and within 60 days if it is for a service you already received. At the end, the company must give you a written decision that tells you how to ask for an external review if it still denies the service or the payment.

In an urgent situation, you can request an external review even if you have not finished every internal step. HealthCare.gov says you can file an expedited appeal if the standard timeline would seriously jeopardize your life or your ability to regain maximum function. You may file the internal appeal and the external review at the same time. A final decision must come as quickly as your medical condition requires, and at least within four business days after the request is received. It can be delivered verbally, and a written notice must follow within 48 hours.

For external review, you must file a written request within four months after the date you receive a notice or a final determination that the claim has been denied. A standard external review is decided as soon as possible and no later than 45 days after the request was received. An expedited external review is decided as soon as possible and no later than 72 hours, or sooner if the medical urgency requires it.

Your explanation of benefits or the final internal denial should name the organization that handles the external review. State processes apply where the state process meets federal standards. Where it does not, HealthCare.gov says HHS oversees a federal process. Use the contact on your letter. That letter is what names the desk with your file.

Papers to keep

HealthCare.gov says to keep copies of everything related to the claim and the denial, including:

• Explanation of benefits forms or letters showing what was denied
• A copy of the internal appeal you sent
• Any extra documents you sent, such as a letter from the doctor
• A copy of any form you sign if a doctor or someone else files for you
• Notes and dates of phone calls, including the day, time, name, and title of the person you spoke with, and what was said

Keep originals where the instructions say to, and send copies unless the plan requires the original appeal request. Write down the member ID, the claim number, and the subscriber's information if the plan is in someone else's name.

A letter from the treating clinician is one of the items the page tells you to submit. The clinician can describe the substance, the withdrawal risk, the level of care, and why a shorter stay or a lower level of care does not fit. You may appoint a representative, such as a doctor, to file. A general description does not claim that a particular phone call between clinicians is required. Ask the plan what it accepts, and ask the program what it will send.

Parity does not erase a medical-necessity denial

CMS explains the Mental Health Parity and Addiction Equity Act this way: if a group health plan or issuer provides mental health or substance use benefits, financial requirements and treatment limitations cannot be more restrictive than the predominant requirements applied to substantially all medical and surgical benefits. The same page states that MHPAEA does not require plans to cover mental health or substance use benefits in the first place.

The Affordable Care Act builds on that rule for non-grandfathered individual and small-group plans by requiring coverage of mental health and substance use disorder services as an essential health benefit. HealthCare.gov says Marketplace plans cover substance use disorder treatment. Network rules and medical-necessity review can still apply. A denial can be legal and still be worth appealing. A denial can also be the wrong comparison with other medical benefits. The letter should say which reason the plan used. Quote that reason in the appeal. Do not replace it with a general argument that "rehab should be covered."

Do not assume the bill pauses

Nothing on the HealthCare.gov appeal pages says the plan keeps paying for each additional day while you appeal. Ask the plan and the program, on the day of the denial, what happens to the charges if you stay. Ask whether a lower level of care is available while the dispute continues.

If the stay is not affordable without that authorization, look at other paths the same day. The guide on paying for rehab without insurance covers public routes such as block-grant-funded care. The federal locator is still FindTreatment.gov. SAMHSA's helpline, 1-800-662-HELP (4357), refers people to local treatment.

SmarterRecovery's how-it-works page says the referral service checks benefits before you commit. The insurance page says a specialist can ask a carrier about authorization, deductible and copay exposure, and network status. That conversation is not an appeal, and it is not the plan's final decision. If a non-VA plan denied care for a Veteran, the Veterans treatment guide covers a separate set of doors. Privacy questions about what the appeal file contains are on the confidentiality guide.

Call or text (800) 653-9376 if you want a benefits conversation tied to programs while an appeal is pending. Bring the denial reason in your own words.

Additional Resources

Sources cited on this page:

• HealthCare.gov: How to appeal an insurance company decision
• HealthCare.gov: Internal appeals
• HealthCare.gov: External review
• CMS: The Mental Health Parity and Addiction Equity Act (MHPAEA)
• Medicare.gov: How do I file an appeal
• HealthCare.gov: Mental health and substance abuse coverage
• SAMHSA FindTreatment.gov
• SAMHSA National Helpline
• 988 Suicide & Crisis Lifeline
• SmarterRecovery: How it works
• SmarterRecovery insurance page

Common Questions