There are several things you can do. First of all call the hmo's customer or member services line, should be a number on your card. Ask for the appeal process. Also reverify your mental/nervous outpatient benefits. They are usually limited, most are 20 outpatient visits per calendar. I want everyone to understand that this is the GENERAL rule for most all insurances...........as I have said over and over, the employer who provides your coverage, no matter how much you have to pay into it, they are still the provider, THEY are the ones who make the ultimate decision as to what coverage you get. It is all based on the previous utilization of their employees....the more the employees and dependents use medical and mental health providers, the higher the employers premiums are to the insurer, or third party administrator. This is to cover the risk of a catastrophic illness or injury. Most employers have consistently shorted mental health benefits in lieu of medical because there is not as much utilization. Do I like this or agree with it? Absolutely not, but that is the way it is. I actually worked for two Blue Crosses, one true HMO and one national HMO/PPO insurer, and NONE of them had very good mental health coverage. It is why there has been legislation passed in some states to help equalize the situation. But so far it has not passed at the federal level. ALSO if your employer is a SELF INSURED group, that means the employer carries all the risk, they are under the ERISA codes, which exempts them in many areas. Now sometimes that is a good thing, as sometimes when you have a self insured employer they will go to bat for the employee and tell the carrier to go ahead and make exceptions. However the bad thing for the employer then is that if they do it for one,they do it for all.
So after all that, check to see what the benefit actually is. I always advise folks on here that they should do that, as well as ensure themselves that if referrals are needed they check on that as well. Doctors offices are notorious for saying they'll get the referral and then get busy or for one thing or another and don't do. Then the employee may be liable.
Once you know you are truly out of benefits, start the appeal process. HMO's have been mandated to have them in place and most have expedited appeals. If it is a PPO plan you may be able to continue visits but pay a larger portion. You will need the psychiatric provider who is seeing your child to write a letter of explanation stating why interruption of services would be detrimental. Let me know what you find out. BLUE
PS just saw Mel's answer, but want to reiterate they can deny if the benefit is gone if it is a self insured employer group. It has nothing to do with the medical necessity, it means there is just no benefit for that particular service. That is what is an example of the self insured group plans having this option.BLUE
