Health plans may tell patients they won’t cover services or treatments that aren't “medically necessary." Here's what you can do to assist a patient.

Ask the insurer for more information

While your patient submits an appeal, you can use the Mental Health and Substance Use Disorder Parity Disclosure Request form to ask for more information about treatment limits or the reason for the denial. You'll need your patient’s permission to submit this form.

Note: Submitting this disclosure request form does not replace the insurer's appeals process.

To file a disclosure request form, follow these steps:

  1. Fill out all required information. If you need help, contact the insurer.
  2. Send it to the insurer. They have 30 calendar days to respond.

If the insurer doesn't respond within 30 calendar days, you may file a complaint with us.

When you should file a complaint with us

You can file complaints about the following issues:

  • Submitting credentials to insurers
  • Equal payment for telehealth and chiropractic services
  • Equal coverage for mental health care

You can also file complaints for patients about the following issues:

  • Disagreements over insurer approval for services (prior authorization)
  • Delayed or denied claims
  • Equal coverage for mental health care

Your complaint might include information that the Health Insurance Portability and Accountability Act (HIPAA) covers. If it does, your patient must give permission by signing a release of medical information.

To learn what to expect after filing a complaint, read about what we can (and can’t) do.

We follow public disclosure rules. This means members of the public can request documents we exchange with insurers. For more information, see our complaint privacy statement. If you have questions about what information the public can request, contact our Public Records unit.

What you need to know about filing complaints with insurers

Under state laws and rules (RCW 48.43.055 and WAC 284-170-440), insurers offering fully insured plans must have a way to review complaints from providers.

  • Insurers must give you a way to submit a written request asking them to review a complaint.
  • If an insurer denies your complaint, you may try to resolve it through mediation. However, the mediator can't make a final decision.
  • Insurers must have a way to resolve disagreements over your contract.
  • You can start the complaint process up to 30 days after an issue happens.
  • For billing disagreements, insurers must make a decision within 60 days. For all other disagreements, they must make a decision within a reasonable amount of time.
  • If you're filing a complaint for a patient, you must follow their health plan's complaint process.

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