Counseling Insurance Denial

Page Contents:

• What is Counseling and Who Does It Serve?
• What Types of Conditions Require Counseling?
• Does Insurance Cover Counseling—and Why is Treatment Denied?
• What Should You Do if Your Coverage is Denied for Counseling Services?

Counselors assist individuals in identifying potential solutions to problems that have caused emotional turmoil in their lives. Counselors also seek to improve coping skills, strengthen self-esteem, and promote optimal mental health through behavioral changes. Counseling can be completed in months, or could conceivably take years, depending on the issue. Sometimes referred to as “therapy” or “psychotherapy,” there are many different types of counseling including:

• Individual counseling gives a person the opportunity to receive support and deal with personal issues, including substance abuse, depression, anger, and anxiety.
• Couples counseling can help couples resolve conflicts and heal old wounds. Couples counseling can help couples stay together while establishing realistic goals and expectations.
• Family counseling can take many different forms—the entire family together, or individual family members seen separately. Issues addressed in family counseling may include sibling conflict, the loss of a family member, parenting issues, or dealing with any major change or issue that affects the family as a whole.
• Group counseling helps those with issues feel as though they are not alone in their challenges. Group members discuss their struggles, as the counselor helps them find solutions. Counseling groups usually have up to 8 participants—sometimes more—and one or two group leaders. The group discussion revolves around a specific topic like divorce, domestic violence, substance abuse, anger management, or recovery.

Many different problems, conditions, and issues can benefit from counseling, including the following:

• Depression
• Relationship issues
• Substance abuse
• Recovery from substance abuse
• Stress
• Anxiety
• Addictions
• Compulsions
• Sexual problems
• Grief and loss
• Anger
• Career choices
• Family issues
• Parenting problems
• Phobias
• Fertility issues
• Chronic insomnia
• Dealing with cancer or other life-changing illnesses
• Eating disorders (anorexia, bulimia, and other eating disorders)
• PTSD
• Personality disorders
• Chronic pain
• Domestic abuse

Sometimes a provider will recommend more intense mental health programs when counseling isn’t sufficient. These programs include an intensive outpatient program, a partial hospitalization program, and a residential treatment center program.

While most U.S. insurers do cover mental health issues in the same way other medical issues are covered, it’s important to carefully read your policy to see exactly what’s covered, and how much your co-pay will be. If counseling is covered under your policy, you likely will have to choose a provider who is in-network. Since “therapy” is a very broad term, you may have to delve into billing codes. As an example, the most commonly used billing codes for mental health services include:

• Intake interview (90791) refers to your first session with a counselor where information regarding your symptoms and your history is gathered
• One-hour counseling session (90837) refers to any counseling session that lasts 53 minutes or longer. It is of note that some insurance plans do not cover any counseling session that is longer than 45 minutes, so this is an important distinction.
• Forty-five-minute counseling sessions (90834)
• Thirty-minute counseling sessions (90832) are usually reserved for children who have a shorter attention span.

In addition to denying a claim for counseling because it is not covered by the insurer, your insurer could deny a claim for counseling because they deem it to be not medically necessary, or because they believe it is an experimental form of counseling.

Your counseling services could be denied by your insurer, whether you have Anthem Blue Cross, Blue Shield, Aetna, Kaiser, Health Net, UnitedHealthcare, or another insurer. If your coverage is denied, your insurer must send you a letter that states why the counseling services were denied. Your doctor may be able to send a letter asking for a medical exception for the treatment, or you may need to file an appeal. Understandably, this can seem like an overwhelming proposition. Having a strong legal advocate on your side can make all the difference in the outcome.

The Law Offices of Scott Glovsky is ready to help you get justice following a counseling insurance denial. We understand that you have spent years paying health insurance premiums and that such a denial can not only be discouraging, but can also be potentially damaging to your physical or mental health. Attorney Scott Glovsky will fight for your rights following a counseling insurance denial so you can receive the treatment you need. Contact our firm today.