When care is denied, a health plan member or provider has the right to complain (about the quality of care or coverage) or to ‘appeal’ (ask for a different decision). Complaints and appeals are a standard part of the insurance business. State and federal agencies need complaints and appeals because they are helpful in finding out where the problems are and making the parity law stick.
How to prepare a complaint
- Member and provider discuss the reason for the complaint or appeal. Write down the details.
- Member or provider contacts the health plan customer service office to ask for a different decision.
- If not resolved, the member or provider files a written complaint with the health plan.
- At the same time, the member or provider should contact the Tennessee Department of Commerce and Insurance’s Division of Consumer Services:
- For more information
- For help filing a complaint with the health plan
- To file a complaint with the Department or another government agency
It is important to let regulators know if you think your, a family member’s or your patient’s parity rights have been violated. But remember—a complaint to a federal or state agency charged with enforcing the mental health parity laws does not take the place of filing an appeal with your health plan.
If you believe you have been denied medically necessary care that should be covered by your plan you must appeal within the required time to preserve your rights.
You can file a complaint with state and/or federal regulators at the same time or wait until you have completed your appeal. Even if you win your appeal you should report suspected violations of the parity laws. You will help ensure that health insurance plans follow the rules and provide the coverage they should for everyone.
Reporting violations
State and federal agencies share authority for enforcing the parity laws. Once you determine the kind of health plan you have, you can find the contact information below for the appropriate agency or agencies that can best handle your parity complaint.
- TennCare
- Tennessee Department of Commerce and Insurance
- Department of Labor
- Department of Health and Human Services/ Centers for Medicare and Medicaid Services
TennCare is Tennessee’s Medicaid program. It contracts with Managed Care Organizations (or health plans) to manage it members’ health care. Appeals about TennCare plans can also be filed with CMS.
Website: How to file a medical appeal
Phone: 1-800-878-3192 TTY/TDD: 1-866-771-7043
For fully insured plans, whether individual, through private employer or non-federal government employers in Tennessee, file your parity complaint through their online complaint portal.
Website: TDCI Online Complaint Form
Phone: (800) 342-4029 or (615) 741-2218
The Department of Labor Employee Benefits Security Administration handles parity complaints involving self-insured private employer health plans and health plans sponsored by employers with 50 or more workers.
Website: www.askebsa.dol.gov
Phone: (866) 444-3272
CMS handles parity complaints involving state and local government employer plans that are self-insured.
Website: Mental Health and Addiction Insurance Help portal
Phone: (877) 267-2323 ext. 6-1565