Filing a Complaint
What Does a Parity Violation Look Like?
Consumers and providers have increased protections because of the Federal Parity Law, but it is up to all of us to take advantage of these rights and hold insurers accountable. If you, a loved one or client are not receiving care that is needed, take action and file an appeal with your insurer or a complaint with the proper government agency. You can do this on your own following the steps below.
Step 1: Figure Out the Type of Plan You Have and Which Government Entity Can Help
Your rights and benefits depend on how you are insured. If you get insurance through your employer, the laws governing your plan differ depending on whether your plan is self or fully insured. Rules are different for individual policies and government plans. If you don’t know your plan type and get insurance through your employer, ask your benefits representative or call the number on your insurance card.
Step 2: Obtain Written Reason for Denial
If you have been denied coverage or reimbursement for treatment, your insurer must provide you and/or your provider with a reason for this denial in writing. If you have not received this document, you have the right to request it from your insurer, free of charge and in a timely manner. You can call your insurer with your member number and the date of treatment request to get this document.
Step 3: Ask for Help
Your provider can help with appeals to your insurer. He or she is often the first to receive billing information, including denials from insurers, and may have information you need in order to continue the process. Sometimes your provider may have already filed an appeal on your behalf. If you decide to file the appeal alone, you should notify your provider because the insurer may need to speak with him or her. The Maryland Attorney General Health Education and Advocacy Unit will also help with appeals of treatment denials.
Step 4: Gather Materials
The items listed below may be useful if you continue through the appeal process. Collecting documents and taking notes can be tedious but are often very important to winning an appeal.
- Explanation of Benefits Booklet
This is the book you should have received when you first got your health insurance information. It may outline the appeals process. If you don’t have a copy, you can request one from your insurance company or from your insurance representative at your employer. It can sometimes be found online.
- Reason for Denial of Treatment or Reimbursement
This must be presented to you timely and free of charge.
- Definition of Medically Necessary
The insurance company must provide you with written criteria it uses to determine whether your treatment was medically necessary and an explanation of how it applied this criteria.
- Letter Explaining Necessity of Prescribed Treatment
Your provider will give you a letter describing why your treatment was necessary.
- Medical Bills and Tracking of Visits
Keep copies of bills and records of visits for treatment. When in doubt keep any documents you receive about your treatment until the appeal and complaint process is complete.
- Good Notes
Document all calls and conversations you have regarding your appeal. Keep track of names and dates of all conversations
Step 5: File An Appeal With Your Insurer
Make sure to do this within the time allotted. If you are unsure of the process or deadlines, call your insurer or your benefits representative at your employer or call the number on the back of your insurance card.
Step 6: File a Complaint
You can file a complaint of a potential parity violation at any time, but after you have exhausted internal appeals with your insurer, you can ask for an external review of the denial. This is done by filing a complaint with the proper government agency. In the complaint letter be sure to reference the Federal Parity Law and any potential violations. We have prepared some sample letters that you may use to file a parity complaint. Most complaints are filed with the Maryland Insurance Administration (MIA). Exceptions are the following:
- Complaints for large employer, self insured plans and complaints for state and local government plans are filed with the US Department of Labor
- Complaints for federal government plans are filed with US Health and Human Services
SAMPLE Complaint Letter Prior Authorization
SAMPLE Complaint Letter Inability to Find Provider
SAMPLE Complaint Letter Fail First
SAMPLE Complaint Letter Allowable Amount