Mental Health Utilization Review Bill

Below is a summary of the Mental Health Utilization Review bill, excerpted from "Fighting for Parity in an Age of Incremental Health Care Reform: A Battle Against Discrimination in the Health Care Industry" by Ken Libertoff, Ph.D.

Mental Health Utilization Review Bill - A Summary

Now You Can Do Something When Mental Health Care Coverage is Denied

The world of mental health care is changing rapidly. Today, health care plans use "review agents" to help keep down the rising costs of mental health care. A review agent is a company that reviews mental health care services and decides whether the services should be paid for or covered.

Even if your mental health care provider recommends that you receive treatment, a review agent can deny payment for that treatment if the review agent decides that the treatment is not appropriate or is not covered by your health care plan.

In the past, there was little you could do if a review agent denied you coverage for mental health care treatment. Today, however, you can appeal the denial of coverage to the Independent Panel of Mental Health Care Providers. If your appeal is successful, the review agent could be required to approve coverage for the recommended treatment.

What is the Independent Panel?

The Independent Panel of Mental Health Care Providers is a panel of mental health care professionals. The panel was created by the Vermont Legislature to hear appeals from consumers who have been denied mental health care benefits as a result of a decision of a review agent.

The panel includes a drug and alcohol counselor, a psychologist, a social worker, a psychiatrist, a mental health counselor and a psychiatric nurse. Panel members are appointed by the Commissioner of the Department of Banking, Insurance, Securities and Health Care Administration and serve without pay.

How the appeal process works

Before you can appeal to the Independent Panel, you must first appeal the denial of coverage directly to the review agent. Vermont law requires every review agent to have an internal appeal process available to you at no cost. Appeals must be decided within ten days. In case of an emergency, the review agent must make a decision within 24 hours of receiving your appeal.

If the review agent denies your appeal, you may appeal the review agent’s decision to the Independent Panel of Mental Health Care Providers. The Independent Panel will review your medical records and the review agent’s decision.

If the Panel decides that the treatment recommended by your mental health care provider is appropriate and is covered by your insurance contract, the Panel may order the review agent to approve payment for the recommended treatment.

How to appeal to the Independent Panel

The appeal process is simple. You may file the claim yourself, or it may be filed by your mental health care provider or a personal representative (if you give your consent). Pre-paid appeal forms are available from the Department of Banking, Insurance, Securities and Health Care Administration (802-828-3301) in Montpelier. You do not have to use the pre-paid forms, as long as the appeal is in writing and contains the following information:

• The name and address of the patient;
• The name and address of the mental health care professional providing treatment (and the providers credentials, if known);
• The name and address of the review agent (you can get this information from your mental health care provider or your insurance provider);
• A brief description of the decision which is being appealed;
• A statement of whether the appeal requires emergency review; and,
• The patient’s consent to release his or her files to the Independent Panel.

You may mail, fax or hand deliver your appeal to the Department of Banking, Insurance, Securities, and Health Care Administration. If you want to fax your appeal, please call ahead to make special arrangements to protect your privacy. The address, phone, and fax are:

Chairperson, Independent Panel of Mental Health Care Providers
Department of Banking, Insurance, Securities & Health Care Administration
89 Main Street, Drawer 20, Montpelier, VT 05620-3101
Phone: (802) 828-3301
Fax: (802) 828-3306