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Information for Advocates

Information for Advocates

Advocates

As an advocate, there are several ways you can assist someone to understand, and sometimes appeal, their mental health and substance use disorder benefits and/or claim decisions. 

Helping Someone Understand Their Benefits

Understanding the type of plan someone has will help them determine their mental health and substance use disorder benefits. Before utilizing their mental health and substance use disorder benefits it is important to understand where their insurance comes from and what coverage is available under their plan.

If the person you are assisting is unsure if their plan offers mental health and substance use disorder benefits you can help them identify that information by having them:

  • Check the certificate of coverage issued by your insurer or provided by your employer
  • Contact your human resources office
  • Contact your insurer directly (there should be a telephone number on the back of your insurance card) 
  • Contact your insurance agent
  • Contact ODI’s consumer hotline at 800-686-1526

You can also use this coverage chart to help you determine what type of coverage you may have under your health plan.

Appealing a Claim Decision on Someone's Behalf

An advocate, working with someone who disagrees with a decision that was made by their health plan regarding any claim denial, or reduction in benefits (often referred to as an adverse benefit determination) can be deemed by the person they are working with as their authorized representative and can appeal the adverse benefit determination under Ohio Law. This could include benefit denials, prior authorization denials, and reductions in the length of stay for an inpatient facility. If the person the advocate is working with has received a decision like this an advocate, acting as an authorized representative, can appeal that decision on their behalf.

To begin the process, notify the person’s insurance company of the person's intent to appeal.  The initial appeal is conducted internally by the insurer. If the insurer upholds its original determination, then an advocate acting as an authorized representative can notify the person’s insurer that the person intends to appeal to the Ohio Department of Insurance (also referred to as an "external review").  Once the person’s insurer has been notified that the person has requested an external review, the person’s insurer will send all the necessary paperwork to the department to begin the process. When the external review is completed, the advocate is notified that a final determination has been made.  External reviews are binding on the insurance company.

If the person is experiencing an emergency and their life is in serious jeopardy or they are unable to regain function if treatment is delayed an advocate acting as an authorized representative can request an expedited review by calling the person’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.

The appeal process is included in ODI’s Mental Health Parity Advocates Guide.

Filing a Consumer Complaint on Behalf of a Person

If the person you are working with 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 several steps to identify if the person’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 person it will be helpful if you will need to have the following information handy: 

  • The name of their health plan 
  • Their 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 an 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 they have or the company has sent related to the dispute.

You can file a consumer complaint on behalf of a patient by:

If someone 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 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 person may not want to file a complaint with the department for one reason or another. Or as an advocate, you may notice abnormalities in the way insurance companies are handling the person’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 following the ODI Ombudsman at ombudsman@insurance.ohio.gov.

The appeal process is included in ODI's Tips for Providers