For Consumers

How to help patients who receive a denial from their health plan

Health plans must provide patients and providers the reasons for denying coverage or reimbursement to patients.

Patients may receive a notice from their health plan that a service or treatment won’t be covered because it is not “medically necessary. If the patient  asks for your help to appeal the denial, and you're preparing a letter to address the medical necessity issue, the American Psychiatric Association has developed guidance on crafting a “medical necessity” letter (journals.lww.com).  

Fill out the disclosure requirement form

In addition to the patient submitting an appeal to their health plan, providers (with their patient’s permission) can use the Mental Health and Substance Use Disorder Parity Disclosure Request form (www.dol.gov) to request more detailed information about treatment limitations or specific information about why benefits were denied. 

Note:  Submitting this disclosure request form does not replace the patient’s insurance company’s grievance and appeals process. 

If you choose to file this disclosure request form for the patient, follow these steps:

  • Fill out all required information in the form. If you need help filling it out, contact the patient’s insurance company.
  • Send it to the patient’s insurance company (they have 30 calendar days to respond).

If you don’t receive a response from the insurance company within 30 calendar days, you may file a complaint with our office.

When providers should file a complaint with the OIC

You can file a complaint with our office for the following issues:

  • Credentialing 
  • Payment parity issues for telehealth and chiropractic services
  • Mental health parity 

You can also file a complaint on behalf of your patient with our office for the following issues:

  • Prior authorization disputes for patients
  • Claim delays or claim denials for patients 
  • Mental health parity 

If you provide any HIPAA-sensitive about your patient, your patient must give their consent through a signed release of medical information.

For more information on what to expect from our complaint process, please read What we can (and can’t) do.

Our office is subject to public disclosure. Any documents exchanged between our office and carriers are subject to public disclosure requests. For more information, you can review our complaint confidentiality statement. If you have any questions about what information is subject to public disclosure, contact our Public Records unit.  

What providers need to know about the complaint process with insurance companies

Each insurance company offering fully insured plans must have procedures to review complaints submitted by providers (RCW 48.43.055 (leg.wa.gov) and WAC 284-170-440 (leg.wa.gov)).

  • Insurance companies must provide a process for providers to submit a written request for review of a grievance or complaint.
  • A rejected complaint may be submitted to nonbinding mediation.
  • Contract disputes must include a formal process for resolution.  
  • Insurance companies must allow at least 30 days from the contested issue for providers to initiate the complaint process. 
  • For billing disputes, the insurance company must make a decision within 60 days. All other disputes must be made in a reasonable time. 
  • Complaints on behalf of a patient are subject to the grievance processes as outlined in the patient’s health plan.