Mental Health and Substance Use Disorder Benefits Toolkit

Understanding Your Coverage

• Check the certificate of coverage issued by your insurer or provided by your employer
• Contact your human resources office
• Contact your insurer directly
• Contact your insurance agent
• Contact ODI’s consumer hotline at 800-686-1526

How to File a Complaint

• 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 Individual Complaint
• Complaint Form

How to Appeal a Claim Decision

Ohio law gives you the right to appeal ANY adverse determination that the insurance company makes.  This includes benefit denials, prior authorization denials, and reductions in the length of stay for an inpatient facility.  You are entitled to this appeal even in cases where you do not receive a denial in writing.  Appeals are easy and are requested through your insurer. 

The first step to the process is to notify your insurance company you want to appeal.  This initial appeal is conducted internally by the insurer. If your insurer upholds its original determination, then you need to notify them that you want to appeal to the Ohio Department of Insurance (also referred to as external review).  Once you notify your insurer you want an external review, they will proceed and send all the necessary paperwork to the department to begin the process. Once the external review is completed, you are notified that a final determination has been made.  External reviews are binding on the insurance company. 

Here are a few examples:

• You or a family member went to residential treatment for a mental health condition or substance use disorder. A request was made to the insurance company to extend the stay to continue treatment. Your insurance denied the request to extend the stay in residential treatment stating the extension is not medically necessary. At this point you are eligible for the appeals process, including external review. Further, if your provider believes your health or life may be in serious jeopardy or you may not be able to regain maximum function if treatment is delayed while you wait for a decision, you may be eligible for an expedited review for a faster decision.
• You or a family member have been attending weekly therapist sessions for a mental health condition or substance use disorder for a month. The insurance company denied your most recent claim stating that you have met and or exceeded your visit limit and will no longer continue to cover the weekly sessions going forward. You are eligible to appeal the denial received.
• You or a family member were recently diagnosed with a mental health condition. Your provider writes a prescription for a certain drug to treat this mental health condition; however, the insurance company denies covering that prescribed medication.  The insurance company states you will have to pay out-of-pocket for the denied medication, or they will cover a different medication than what your provider prescribed you. You are eligible to appeal the denial received.

These are only examples, all appeals are decided based on the policy language on file with the department and the medical information provided, as applicable. 

To learn more about how to appeal a decision by your insurance company, visit the Understanding Health Coverage and the External Review Appeals Process page.

Advocate Information

• 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

• Advocate Tip Sheet