parity resource guide for addiction & mental health ... ... parity non-compliance and report parity

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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

    Foreword

    Acknowledgements

    PART I: Executive Summary

    Resource Guide Overview Frequently Asked Questions (FAQs)

    Model Appeal Letters

    PART II: Parity Background Parity Law Overview

    Exemptions

    Cost Exemptions

    Common Parity Compliance Issues

    Parity Rule Summary

    Final Regulations Overview

    Scope of Service

    Parity Testing Criteria

    Disclosure and Transparency

    Enforcement

    Medicaid Managed Care, CHIP and Alternative Benefit Plans

    Other Issues

    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

    administrative appeal?

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    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?

    Administrative/Grievance Appeal

    What is an administrative appeal?

    What are the sources of the regulations?

    What are the new federal appeals procedure protections?

    Internal Review

    External Review

    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?

    Accreditation Audits

    How can an individual initiate a complaint about a health plan with an

    accreditation agency?

    What is an accreditation audit?

    Arbitration

    What is an arbitration appeal?

    What rules govern arbitration?

    Commercial Insurance

    Self-Insured

    When should an individual or provider initiate an arbitration appeal?

    Judicial Action

    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

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    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

    Treatment Interventions

    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:

    Service Coding

    Appendix C: Helpful Resources State Resources

    State Insurance Regulators

    Federal Resources

    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

    Equity Act.

    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

    received treatment.

    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

    Fo re

    w o

    rd

  • 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 info@parityispersonal.org or info@thekennedyforum.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.

    mailto:info@parityispersonal.org mailto:info@thekennedyforum.org

  • 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

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