If a request for treatment is denied, the patient and clinician have the right to appeal. The appeals process varies from plan to plan. The initial appeal may take the form of a telephone conversation between the clinician and a doctor on staff at the MCO. If the two are unable to reach an agreement on the course of treatment, the case will go to a second round of appeals. At this stage, plans generally invite the clinician to submit the patient’s full medical record. In general, to pursue their appeal, providers need to submit it.
One provider stated that, in lieu of releasing the entire record in the second round of appeals, he can sometimes prepare a summary of additional information that the plan needs. However, other providers we spoke with said that, in their experience, plans always require the full record in order to review the case. One provider mentioned that when he calls an MCO, he usually speaks with a clerical person, not a psychiatrist or psychologist. Since that person does not know what information will be required for the appeal, the provider is simply told to send everything.
"MHPrivacy.pdf" (pdf, 768.25Kb)
"appen-b.pdf" (pdf, 224.4Kb)