Anonymous wrote:If there is no coverage for OON providers, the only possible grounds for an appeal is if there are no providers available within a reasonable distance. If you are simply choosing an OON provider over an in network one, you’re most likely SOL.

Not OP, but there are no in network OCD therapists.

If there is no coverage for OON providers, the only possible grounds for an appeal is if there are no providers available within a reasonable distance. If you are simply choosing an OON provider over an in network one, you’re most likely SOL.

Usually if the insurance coverage you have covers mental health, you will receive some benefit, just have to pay up front and file a claim. Most good therapists do not accept insurance unfortunately.

The IOCDF has some good info: https://iocdf.org/ocd-finding-help/navigating-insurance-for-ocd-care-coverage/

Also to supplement my prior response above, keep copies of whatever you submit and keep appealing. This process is designed to wear you down.

Check your benefits manual and see if there is an out of network option that can be available if no provider in network is available within a reasonable time and distance to see your child. Basically, you have to show as prior PP did that their network is "illusory" and an out of network provider is needed. Also if you have the opinion of an M.D. that these services are medically necessary then whoever is reviewing the decision should have at least the same level of licensure/qualifications. You should have someone who is at a lower licensure level so to speak second guessing the medical judgment of an M.D.

Anonymous wrote:DC uses an out of network therapist, and I got it covered on appeal. I had to prove no in network option was available (I read the insurance benefits guide to figure this out, and also used AI). I did this by searching for in network options in close proximity to our house. Then I contacted all of these providers to inquire about in person sessions (I argued virtual wouldn't work bc of ADHD and age), specialty with children, and after school hours (arguing school would get worse of they had to regularly miss, adding to anxiety). This resulted in NO in network providers. I appealed - rejected. I appealed again, approved.

Great info-thanks for sharing. Congrats on this!

Anonymous wrote:

Anonymous wrote:DC uses an out of network therapist, and I got it covered on appeal. I had to prove no in network option was available (I read the insurance benefits guide to figure this out, and also used AI). I did this by searching for in network options in close proximity to our house. Then I contacted all of these providers to inquire about in person sessions (I argued virtual wouldn't work bc of ADHD and age), specialty with children, and after school hours (arguing school would get worse of they had to regularly miss, adding to anxiety). This resulted in NO in network providers. I appealed - rejected. I appealed again, approved.

PP here - adding, I kept a detailed log of each therapist I contacted and the reason it wasnt an option for DC. I submitted this with the appeal.

Good for you! Which insurance?

Anonymous wrote:DC uses an out of network therapist, and I got it covered on appeal. I had to prove no in network option was available (I read the insurance benefits guide to figure this out, and also used AI). I did this by searching for in network options in close proximity to our house. Then I contacted all of these providers to inquire about in person sessions (I argued virtual wouldn't work bc of ADHD and age), specialty with children, and after school hours (arguing school would get worse of they had to regularly miss, adding to anxiety). This resulted in NO in network providers. I appealed - rejected. I appealed again, approved.

PP here - adding, I kept a detailed log of each therapist I contacted and the reason it wasnt an option for DC. I submitted this with the appeal.

DC uses an out of network therapist, and I got it covered on appeal. I had to prove no in network option was available (I read the insurance benefits guide to figure this out, and also used AI). I did this by searching for in network options in close proximity to our house. Then I contacted all of these providers to inquire about in person sessions (I argued virtual wouldn't work bc of ADHD and age), specialty with children, and after school hours (arguing school would get worse of they had to regularly miss, adding to anxiety). This resulted in NO in network providers. I appealed - rejected. I appealed again, approved.

Can you clarify on what grounds you are appealing? Do you have OON benefits but they are denying claims even after meeting the OON deductible? Or is it that there are no available in-network providers? If that’s the case, you can ask your insurer about a single case agreement to get coverage with an OON provider but some OON providers won’t be willing. DS sees an OON therapist because we didn’t like the in-network options so we pay out of pocket and submit for reimbursement. It’s expensive. We pay $250 but the allowable rate is only $115 so even though we’ve spent well over our deductible, we haven’t actually met the deductible and might not meet it by the end of the year which is frustrating.

Teen has ocd, major anxiety, separation anxiety (won’t leave house unless school), adhd. OCD and anxiety Therapist is out of network. So no coverage through our insurance and I am wondering how I can appeal. we are draining all our funds we have left to try to get our teen necessary help. Any ideas? I would like to have AI help me draft appeal.