Has anyone struggled with insurance company not covering testing, treatment, or psychological visits of child with combined ADHD-ODD?

[BlessUsAll]

My current insurance carrier is UMR. To have my daughter tested for ADHD it cost $1,475. The insurance company did not cover any portion of that bill. Since my daughter has combined ADHD and ODD we are seeing a Psychologist. Again, insurance does not cover the costs associated with behavioral issues.

**** I could really use some help writing an appeal letter to request that the insurance company reconsider two previous claims that were denied, as well as, any future claims related to my daughters diagnosis.

[ADHD_DAD]

Not sure what UMR is, but it will most likely cover a psychiatrist (which is a medical doctor) but is unlikely to cover psychologist (PhD). Good thing about a psychiatrist is that he or she can prescribe meds as well.

Read your health insurance plan summary. There should be both an appeal section and a dispute resolution section. Usually, you agree to arbitration (you automatically agree by getting the insurance) but often still have the option of Small Claims court. If so, look up (on line) the rules for whatever small claims court is in the summary (it often includes a specific county or town as the agreed upon venue). With the pandemic, many small claims courts are 100% electronic right now. After you have learned the procedure, and AFTER you have exhausted the appeals process described in your plan summary, write to the insurance company outlining what they did not pay that they were supposed to and advised them that if they do not pay within 30 days, you will launch the small claims action. Then make sure you do it. Don't just threaten. You can proceed in small claims court without a lawyer, but the insurance company will need to involve one which will cost more than just paying your psychologist bills.

Now as for the ADHD testing , if you have it done by a medical doctor (psychiatrist, pediatrician, pediatric neurologist, etc.) I am quite sure they would pay. The public schools must also test for free if requested by you (but that's another story). Good luck.

[ADHD_DAD]

Looks like UMR is a UnitedHealth company. Here is a sample Benefit Booklet from United Healthcare that I found on-line. uhc.com/content/dam/uhcdotc...

I didn’t see any obligation to go to arbitration (rather than bring a small claims action) in this, but you will need to see the one specific to your plan.

I have seen UnitedHealth plans before. The only condition precedent to initiating a legal action that I have seen is that you cannot commence an action until 60 days after you properly submitted a claim (as described in Section 5 in the copy I saw ).

The paragraph regarding a “non-network provider” sets forth the procedure to follow. Briefly, within 20 days of the date of service (psychologist visit), you submit a written notice that you are requesting payment or reimbursement. Within 15 days of that, United is supposed to provide you with forms to fill out to request payment.

You then have until up to 120 days after the psychologist visit to complete and return the forms they provide (BUT, they actually give you up to one year to submit the forms in the next paragraph; even that can be extended if it is “not reasonably possible to provide the required information within that time period”). You have to include all of the “Required Information” listed in the plan. If they dispute that they have to pay, they have to notify you in writing within 30 days of receipt of the info.

If you have done all of this, I see nothing which prevents you from filing a legal action in Small claims court like noted in my last post.. I do NOT see anything which requires you to go through their “Complaint” or “Appeals” process ( Section 6,) before bringing a legal action. They may argue in opposition that you did not exhaust all administrative remedies (if you did NOT go through the “Claims” and “Appeals” process), but I disagree with that.

Of course, you should read your own plan, but they tend to be pretty uniform with regard to this kind of thing. Again, good luck. Keep me advised.