Tips for Working with Your Insurance: Keep Asking, (Politely!)

Publications
#CM40.01

This pub gives you advice about challenging a denial by your health insurance. It tells you to call, appeal and follow up. It gives you sample forms to help you. This pub does not cover Medi-Cal.

It is overwhelming to open a letter from your health insurance plan and learn your claim for mental health or substance use services was denied.  Sometimes, you may not even get a written denial, but your health plan representative tells you that you cannot get the services you need.

The good news is that insurance denials can often be reversed with polite persistence.  If you get an insurance denial, do your best to stay calm and do not put off dealing with the denial.  Read on for tips for working with your health plan to get the services you need.

STEP ONE: Call

Sometimes, you can solve the problem with a simple phone call.  Call your insurance plan’s customer service number right away.  You can use the attached phone log to keep track of calls.  Below are some helpful questions to ask when you call:

  • What is your name and title?
  • Is there a reference number for this call?
  • Can you send me a written explanation for the denial?
  • Why is my insurance claim being denied?
  • If the claim was missing information, how do I re-submit the claim?
  • How do I appeal this decision?
  • Are there any deadlines I should know about?

STEP TWO: Appeal

If you cannot solve the problem with a phone call, appeal the decision in writing.  Even if you do not have a written denial, submit a grievance about the problem that is keeping you from getting mental health or substance use services.  Below are some tips for your written appeal:

  • Always appeal before the deadline. 
  • Be sure to include your name, date of birth, and identifying numbers (such as your ID and group number, or medical record number).
  • Keep your appeal clear, factual, and brief.  State the services you were denied, and why you believe these services should be covered.
  • Attach any supportive documentation that you have (such as a letter from your doctor, or legal justification for why the service should be covered).

If your written appeal is denied, you can often ask for an external review or Independent Medical Review.  This means a separate medical review organization will take a new look at your claim.  Read your appeal denial for information about how to ask for an external review.  (See DRC’s Independent Medical Review Fact Sheet for more information).

STEP THREE: Follow Up

By keeping an up-to-date record of your phone calls and letters, you can save yourself time and hassle in the long run. Below are tips for keeping records and following up:

  • Remember to set a date to follow up about the denial.
  • If you make several phone calls, mention the reference number from your last call. 
  • If you write several letters or appeals, mention the date of previous letters.  If possible, attach copies of related letters and denials.
  • Inform your insurance plan right away of any changes in your contact information, such as your address or phone number.
  • Keep a log of all interactions with your health plan.  You can use the attached phone log, your computer, phone, or even a notebook.

PHONE CALL LOG

Publication #CM40.01 - Phone Call Log for print (pdf)

 

OTHER NOTES:

This information is provided to you through the combined effort of the following organizations:

Disability Rights California
(916) 504-5800/(800) 776-5746

Legal Aid Society of San Diego, Inc.
(877) 534-2524

Mental Health Advocacy Project
(408) 293-4790

Mental Health Advocacy Services, Inc.
(213) 389-2077

 

The California Mental Health Services Authority (CalMHSA) is an organization of county governments working to improve mental health outcomes for individuals, families and communities.  Prevention and Early Intervention programs implemented by CalMHSA are funded by counties through the voter-approved Mental Health Services Act (Prop 63).  Prop. 63 provides the funding and framework needed to expand mental health services to previously underserved populations and all of California’s diverse communities.