As a healthcare provider, there are several ways you can assist your patients in understanding, and sometimes appealing, their mental health and substance use disorder benefits and/or claim decisions.
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Appealing a Claim Decision on Behalf of a Patient
If a patient disagrees with a decision made by their health plan regarding any claim denial or reduction in benefits (often referred to as an "adverse benefit determination"), as the provider you can be deemed by the patient an "authorized representative", which affords you the RIGHT to appeal that decision under Ohio Law on their behalf. This could include benefit denials, prior authorization denials, and reductions in the length of stay for an inpatient facility.
To begin the process, notify the patient’s insurance company of the patient's intent to appeal. The initial appeal is conducted internally by the insurer. If the insurer upholds its original determination, then a provider acting as an authorized representative can notify the patient’s insurer that the patient intends to appeal to the Ohio Department of Insurance (also referred to as an "external review"). Once the patient’s insurer has been notified that the patient has requested an external review, the patient’s insurer will send all the necessary paperwork to the department to begin the process. When the external review is completed, the provider is notified that a final determination has been made. External reviews are binding on the insurance company.
If the patient is experiencing an emergency and their life is in serious jeopardy or they are unable to regain function if treatment is delayed, a provider acting as an authorized representative can request an expedited review by calling the patient’s insurance company.
To learn more about becoming an authorized representative and how to appeal a decision by an insurance company, visit our Health Coverage Internal and External Review FAQs webpage.
To learn more about what to do if your health insurance provider denies your claim, read the Health Insurance Appeal Process handout created for you by the Ohio Department of Mental Health and Addiction Services, Recovery Ohio, and the Ohio Department of Insurance.
Filing a Consumer Complaint on Behalf of a Patient
If a patient has a question or concern about their mental health and substance use disorder benefits or if they are unable to resolve a complaint with their insurer, you can file a consumer complaint on their behalf with ODI's Consumer Services Division (CSD). When filing a complaint, CSD will take a number of steps to identify if the patient’s health plan handled the issue appropriately and within the terms of the policy or certificate of coverage.
When you are ready to file a complaint on behalf of a patient it will be helpful if you will need to have the following information handy:
- The name of your health plan
- Your policy number, group number if applicable (that is the unique identifier that attaches a policy to a specific individual and this number can be found on our insurance ID card)
- A description of what happened and who was involved
- If the complaint involves a dependent under family coverage, identify the person named on the policy
- Include any corresponding letters you have or the company has sent you related to the dispute.
You can file a consumer complaint on behalf of a patient by:
- Calling ODI’s Consumer Services hotline at 800-686-1526
- Emailing Consumer.Complaint@Insurance.Ohio.gov
- Filling out a complaint form online
If you have consumers who would like to file a complaint on their own you can share ODI's Filing a Consumer Complaint information with them or direct them to www.insurance.ohio.gov for additional resources.
Individuals with a self-insured plan can file a complaint with the U.S. Department of Labor by calling 859-578-4680 or by visiting www.DOL.gov.
Individuals who receive Medicaid benefits can file a complaint with the Ohio Department of Medicaid by calling the consumer hotline 800-324-8680 or by visiting www.medicaid.ohio.gov.
Filing an Anonymous Complaint Through the ODI Ombudsman
At times, a patient may not want to file a complaint with the department for one reason or another. Or as a healthcare provider, you may notice abnormalities in the way insurance companies are handling patient’s claims. The Ohio Department of Insurance has created an ombudsman email account where anonymous complaints can be filed regarding a patient or an abnormal trend. All anonymous complaints will be investigated by the department.
As an enforcement agency, it is necessary to have specific information to identify violations of the law and to determine appropriate remedies. At a minimum, the information provided to ODI must contain at least:
- A plan or policy number
- Plan type (i.e., if the consumer gets their insurance through their employer or purchases it on their own)
- Name of the insurance company
- A detailed description of the complaint or what happened – it is NOT enough to simply say the insurance company is violating the law
This information should be submitted to the ODI Ombudsman at email@example.com.