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SIMPLIFYING THE APPEALS PROCESS: STRATEGIES FOR WINNING DISPUTES WITH YOUR HEALTH PLAN
Parity Resource Guide for Addiction &
Mental Health Consumers, Providers and Advocates
WINTER 2015 • SECOND EDITION
Resource Guide Table of Contents
PART I: Executive Summary
Resource Guide Overview Frequently Asked Questions (FAQs)
Model Appeal Letters
PART II: Parity Background Parity Law Overview
Common Parity Compliance Issues
Parity Rule Summary
Final Regulations Overview
Scope of Service
Parity Testing Criteria
Disclosure and Transparency
Medicaid Managed Care, CHIP and Alternative Benefit Plans
Final Rule Enhancements
PART III: Appeals Overview Understanding Appeals
How does the appeals process work?
What types of appeals are there?
How do the internal appeal options differ?
What type of appeal is more common regarding a parity violation?
What are the advantages of adding a parity violation to a traditional clinical or
How is the initial UM determination made?
What are the different levels of appeal?
How are administrative appeals handled?
What are the timeframes to make a decision?
Do appeals cost money?
PART IV: Parity Appeals Background
What is the source of parity regulations?
What information should a person know about their insurance policy?
What does a parity violation look like?
What is the testing methodology to assess whether a parity violation has occurred?
Filing a Parity Appeal
What is a MH/SUD parity appeal?
How should an individual initiate a parity appeal?
What should a person do if the pre-authorization request is denied?
What information does someone need to file an appeal?
What timeframes apply?
What are some tips for a successful appeal?
PART V: Other Appeal Types Medical Necessity/Utilization Management Appeals
What is a utilization management (UM) or “medical necessity” appeal?
What are the sources of regulations?
What is the difference between prospective, concurrent and retrospective UM decisions?
What is an administrative appeal?
What are the sources of the regulations?
What are the new federal appeals procedure protections?
What is an external review appeal?
What are the sources of regulations?
What are the new federal external review requirements?
What is the new expedited federal external review process?
When do state external review laws apply?
Who can initiate a state-based external review appeal?
What types of issues can a state-based external review appeal be initiated for?
How is a state-based external review appeal started?
Filing a Regulatory Complaint
How can government officials help?
How can an individual initiate a complaint about a health plan with an
What is an accreditation audit?
What is an arbitration appeal?
What rules govern arbitration?
When should an individual or provider initiate an arbitration appeal?
Is filing a judicial or court action an option?
When does someone have legal standing to initiate a court action?
What is a class action lawsuit and can it help?
PART VI: Final Thoughts
Appendix A: Terms to Know
Appendix B: Model Appeal Letters Introduction
Using the Templates
Guidance for individuals/providers/advocates using these templates
Sample Appeal Letters
Appeal Letter Sample 1:
Denial Based on Freestanding or Residential Facility-Type Exclusions
Appeal Letter Sample 2:
Denial Based on Level of Care Exclusions
Appeal Letter Sample 3:
Denial Based on Blanket Exclusions of Office-Based Diagnostic and
Appeal Letter Sample 4:
Medical Necessity Denial for Inpatient Services
Appeal Letter Sample 5:
Medical Necessity Denial for Outpatient Psychotherapy
Appeal Letter Sample 6:
Medical Necessity Denial for Non-Psychotherapy, Outpatient Levels of Care
Appeal Letter Sample 7:
Appendix C: Helpful Resources State Resources
State Insurance Regulators
Appendix D: Parity Implementation Coalition Members
Appendix E: Abbreviations
Appendix F: About The Kennedy Forum
Parity Resource Guide for Addiction & Mental Health Consumers, Providers & Advocates06
Often, the most difficult battles are fought after a law is passed. Never has
that been truer than in the case of the Mental Health Parity and Addiction
Today, too many Americans are still being denied the care they need and
are guaranteed under this law. As a result, these individuals and families
often need help filing appeals when their access to behavioral health
services is denied or when their health plans refuse to pay after they have
If you find yourself, a family member or friend in a similar situation, the guide
you are holding is an essential tool to keep by your side as you navigate the
insurance and regulatory systems. Perhaps you’re a provider trying to help
a patient get needed coverage; this guide will help you, too. The goal in
developing this guide is to ensure the best outcomes for you, your loved ones,
friends, neighbors or patients.
While this guide is primarily a consumer resource, advocates like The
Kennedy Forum and The Parity Implementation Coalition will also use it to
educate regulators, legal advocates, legislators and others to ensure that the
Mental Health Parity and Addiction Equity Act and related federal and state
laws are fully implemented and enforced until mental health and addiction
are treated equally.
It’s true that we’ve been engaged in this cause for many years, but this is
really just the beginning. Stay tuned as The Kennedy Forum and The Parity
Implementation Coalition offer additional resources to ensure that you have
the right information and tools at the right time to get the behavioral health
coverage you deserve.
Patrick J. Kennedy
T he Parity Implementation Coalition, in conjunction with The Kennedy Forum, developed this resource guide to help you understand the law, file complaints and appeal denied claims. This resource guide was originally published as a toolkit in 2010, the second edition of which was updated in mid-2015. We will continue to update this publication as regulations are issued and clarified and as additional FAQs are made available.
The information included in this resource guide is meant to be helpful, but does not constitute legal advice or substitute for legal counsel. If you need help with the resource guide or have questions about parity, please send an email to email@example.com or firstname.lastname@example.org.
This resource guide is dedicated to the millions of individuals, families and providers who work tirelessly at fighting addiction and mental illness and ensuring equal rights under the law.
Parity Resource Guide for Addiction & Mental Health Consumers, Providers & Advocates08
We gratefully acknowledge the support from the following organizations (along with their reference materials):
The American Cancer Society Community Catalyst The Consumers Union Kaiser Family Foundation The Kennedy Forum Mental Health America Parity Implementation Coalition The Patient Advocate Foundation Watershed Addiction Treatment Programs
The managing editors: Garry Carneal, JD Carol McDaid, MA Beth Ann Middlebrook, JD Holly Strain, MPH
And the following contributors: Patrick Kennedy Meiram Bendat, JD, Ph.D., MFT Bill Emmet Hen