Prior Authorization
In some cases, professionals caring for your child will need to contact your insurance company to request additional benefits. This usually happens when a specific number of sessions are used, or when a new or different service is being requested.
What Is a Prior Authorization?
A prior authorization (PA) is a request for services your provider submits to your insurance company. In some cases, a PA is necessary after the first two to three sessions with a provider. In other cases, your provider will submit one after a designated number of sessions have occurred so that your insurance company can review your child's care and ensure payment for appropriate service. The PA will give your insurance company information about your child's diagnosis, treatment plan, progress, and any complicating factors. You may be asked to review and sign the plan, which may also be shared with your child. A reviewer will then use the information to decide whether to authorize the requested services.
Medical Necessity
Insurance coverage for mental health is usually based on the concept of medical necessity. Medical necessity refers to the degree to which your child's symptoms impact her daily functioning and interfere with what is considered a normal quality of life. If the symptoms are severe enough, the services your child receives to reduce the symptoms are considered medically necessary. Most care providers are trained to evaluate medical necessity and to use standards of measurement such as the DSM-IV to document your child's symptoms and his response to treatment. The requirement of medical necessity can cause particular problems for a child's treatment. Therapy with children generally proceeds more slowly because of its more subjective nature.
Fact
Often, even though a child's symptoms are reduced, she will need ongoing follow-up to make sure the symptoms stay at bay. In some cases, insurance plans may not cover in these situations, and you may need to be prepared to advocate for your child's continued care.
Denial and Appeal
If your insurance company deems that a PA does not meet the criteria for medical necessity, or if there is information that is missing or needs to be clarified, there is usually a standard appeal process. Sometimes a provider will be asked to send in case notes or other supporting information. Because there may be timelines associated with filing an appeal, you may need to keep in close contact with your provider and/or insurer.
