My mental health or substance use disorder claim is being denied.
Where to start
The reason for any denial of payment for services for mental health or substance use disorder benefits.
The health plan or issuer must provide an adverse benefit determination containing:
- A specific reason for the denial;
- Reference to the specific plan rules used to make the determination; and
- A description of the plan’s appeal procedures.
When can I get these documents?
The time for providing the notice will vary based on the type of claim.
- For urgent care claims, the plan must provide notice within 72 hours of when it received a claim.
- For pre-service claims (i.e., when a service is denied before you receive it), the plan must provide notice within 30 days, with a one-time extension of 15 days allowed.
- For post-service claims (i.e., when a payment for a service is denied after you receive it), the plan must provide notice within 30 days, with a one-time extension of 15 days allowed.
- For concurrent care claims, which involve a determination to continue, reduce, or terminate your current course of treatment previously approved by the plan, the plan must provide notice sufficiently in advance of the coverage termination date to allow you to appeal. Additional rules apply to decisions on requests you make to extend an already approved course of treatment.