In September we worked with a family who had been denied reimbursement for residential treatment provided to their son. The insurance policy holder was a federal employee, and while the employee’s plan included a benefit for residential treatment it required that the treatment be deemed medically necessary. The plan initially approved a short stay, but denied the longer stay that was prescribed by the boy’s treating providers.
We appealed the denial of authorization on the basis that the policies and procedures used to make the decision were more stringent that what is applied to medical/surgical care and therefore not compliant with the federal parity law. The criteria used to determine medical necessity for this treatment established a higher standard than what was used for similar medical benefits.
In December, the Office of Personnel Management overturned the decision of the insurer and required them to reimburse the consumer for the longer stay. The appeal and subsequent decision saved this family thousands of dollars.
If you believe your insurer is not parity compliant or is discriminating on the basis of mental illness or addiction, please contact us to assist you with an appeal or complaint.