FAQs - Private Health Insurance: Mental Health or Alcohol/Drug Treatment
How do I find an in-network provider?
Usually, on the back of your insurance card there is a specific number to call for mental health care. If there is not a specific number then call the customer service number and tell them you need a mental health referral.
Most managed care companies have a computer database that is used to find in-network providers in your area. Using your zip code most often does this. If you are willing to travel outside your zip code be sure to let them know and they will expand the search area.
When you call the provider, be sure to ask if they are accepting new patients and ask if they are still a provider for your insurance. There are frequent changes in provider status and your insurance company's database may not be current.
Can I request a specific provider?
Yes, as long as they are on your provider list. You can ask the customer service representative to check for specific names on the provider list.
What are my benefit limitations?
Your benefit limitations are specified in your policy's Explanation of Benefits (EOB) document, which is part of the paperwork you received when you first enrolled in the insurance plan. You can also call the insurance company. Usually the customer service representative can tell you how many visits of outpatient therapy your plan provides as well as inpatient care limits. They can also tell you what your co-pay will be per session. Be advised, all policies have limits, however, for severe cases of mental disorders you may be able to extend your benefits. Ask to speak with a clinician or supervisor if you have reached your plan limits and need ongoing care.
What if my doctor says I need to be in the hospital for my mental health condition, but the insurance company says no?
You have the right to appeal any decision made by your insurance company or their managed care company. Ask to speak with a supervisor and explain to them that you are requesting an immediate appeal. They will explain the process to you. A psychiatrist who will make an initial appeal determination often reviews the decision.
What if my child has an emergency, after normal business hours?
Many managed care companies have after hours staff to manage inpatient admissions. If your child needs emergency hospital care, go to the hospital immediately. The hospital staff will contact your insurance company for you.
Will a managed care company provide the type of service I request?
People sometimes feel that they do not receive the care they want or need and blame the managed care company. The function of a managed care company is to manage the financial risk for your insurance company. Consequently, they often approve less expensive services before authorizing more expensive care. For example, they may authorize a partial hospital program rather than in-patient care if they believe this will best help your child.
I am frustrated with my managed care company, what can I do?
Call your company and ask to speak with a supervisor. Try to be nice and explain your reason for being upset. Have an idea about what would solve your dilemma and ask for this. Be prepared to ask for the supervisor's supervisor.
What other problems could I face when trying to secure mental health services for my child?
Sometimes insurance companies refer consumers to mental health providers who are either not accepting any new patients, or who are not accepting patients from the consumer's insurance group. This problem frequently occurs if an insurance company has not updated its mental health provider database.
There are several ways to deal with this frustration. First, when you call a mental health provider, always ask up front if they are accepting new patients and whether they are a provider for your insurance group. Second, always try calling all of the mental health providers given to you by your insurance carrier - this should result in several possible matches. If all else fails, call your insurance company and ask to speak with a supervisor to deal with the problem.
Most states also have an Insurance Board that will field complaints about companies doing business in the state.