Insurance coverage for mental health care can be challenging – it can be difficult to find mental health clinicians accepting new patients, claims may be denied, or other obstacles can come up. Despite regulations requiring equal treatment of mental health and medical care, many people seeking mental health care continue to face insurance-related barriers.

Below are a few tips and suggestions to help understand what to expect and address the challenges to accessing insurance coverage for mental health care. This blog was adapted from CoverMyMentalHealth.org, which features more information, tips, and guidance for patients and clinicians.

Lack of Available Mental Health Clinicians

One common barrier is difficulty finding a suitable in-network mental health clinician, one with the right skills and experience, who is reasonably near, and has openings for appointments within a reasonable time.

Reasonable expectations for access to in-network clinicians:

• Medical expertise you need – you should have access to an in-network clinician suited to your needs, who may be for out-patient care (in office or by telehealth) or for higher levels of care such as intensive outpatient, partial hospitalization, or residential
• Within 30 – 45 minutes travel time (or by telehealth) • Soon: within 10 – 14 days for non-urgent care and 2 –3 days for urgent care
• After a search of no more than 10 clinicians who are in-network.

When no in-network clinician is available, insurers may be obligated to cover the cost of out-of-network clinicians as if they were in-network. That is required in some states. To pursue having an out-of-network clinician covered as if they were in-network, make a request in writing. Show that you tried, but failed, to find an in-network clinician and request approval of coverage. See a template request letter from covermymentalhealth.org here: Insurer request for in-network coverage for out-of-network clinician.

The next step, if the request does not result in a timely appointment, is to file a formal complaint with your insurer. Filing a formal complaint with your insurer may be helpful (or even required) before taking further action, such as filing a complaint with a state insurance regulator.

It is important to note that a “formal complaint” is NOT an appeal. An appeal is a formal, legal process that requires very specific steps.

Denials for “Not Medically Necessary”

Insurers may deny claims or withhold authorization, stating that the treatment is “not medically necessary.” The first step is to request a “letter of medical necessity” from your clinician and submit it to the insurance company. The letters can be powerful, authoritative tools for clinicians and patients to ensure access to needed care. The medical necessity letters can also be used preemptively to help ensure that coverage for a treatment you are concerned about is not denied.

More detailed information and guidance for clinicians on writing medical-necessity letters is available in a previous APA Blog post, a Psychiatric News article, and a Journal of Psychiatric Practice paper.

If that process is not successful in resolving the issue, the next step is to request a complete copy of the claim documentation from the insurance company. Then file a “formal complaint” (again, NOT an “appeal”) with the insurance company.

Tips for talking to the insurance company

1. Take notes – Important notes from a call with an insurance company customer service rep include:
   • Date of the call
   • Name and ID number of the person you talked to 
   • Phone number you can use to call them back 
   • Case number (they will provide this) 
   • Any commitment they made and when they would follow up
   • Any instructions you are given for next steps, and any specific timelines mentioned
2. Do not agree to an appeal over the phone. “Appeals” have special meaning with health insurance. Your rights to a formal appeal may be adversely affected by an over-the-phone appeal.
3. Leave medical questions to the clinicians. If a customer service rep asks about how you (or your family member) is doing, try “Thanks for your interest, but I’ll leave that to the doctors.” Anything you say could be used in the future.

More help and resources

• Employer. Your employer may be able to help in your efforts to address not having an in-network mental health clinician available or denials related to “not medically necessary” or access to telehealth.
• State insurance regulator. Every state’s insurance regulator offers consumers an opportunity to “file a complaint” or to otherwise ask for help with an insurance claim. Some states offer online submissions, some offer “live” assistance, and many will help you find additional resources that may be helpful. Find your state regulator (National Association of Insurance Commissioners) and see more information here: Guidance for a state insurance regulator complaint.
• US Department of Labor, Employee Benefit Security Administration. EBSA offers help with private company employee benefits plans, including for mental health benefits (866-444-EBSA (3272) and online at Ask EBSA questions).
• Covermymentalhealth.org. Cover My Mental Health offers extensive resources, including step-by-step instructions and templates, and details about an appeal.