Author Topic: ADHD and 2nd level appeals  (Read 1082 times)

PMRNC

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ADHD and 2nd level appeals
« on: August 08, 2014, 05:20:08 PM »
I've been to the most sophisticated of forums and discussions all over the net.. and don't expect much here either.. I have a client (MD-psychiatrist) who is specializing in adolescent and adult ADHD. We have patients who are coming in with policies that EXCLUDE coverage SPECIFICALLY for ADHD/ADD .. period. These are ERISA based claims. With ERISA claims we know the patient has to do the appeals, however we have authorization for a few patients and we are participating with their plans. We are trying to find out if there are any other successful appeals based on the Disability and Discrimination Act?  We already tried the Parity appeal.. plans are allowed to exclude coverage for a specific condition, with ADD/ADHD being one of them. These exclusions ARE spelled out in the patient's plan. We are trying to see if this is worth pursuing based on the Disability and Discrimination Act. We also understand this would be on a patient by patient basis. Just trying to see if anyone else was successful with an ERISA plan and this type of suit.
Linda Walker
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shanbull

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Re: ADHD and 2nd level appeals
« Reply #1 on: August 11, 2014, 10:57:53 AM »
I am surprised it wasn't allowed based on the parity rules. I think it would be worth a try, as ADHD is categorized as a disability protected by the ADAA under specific circumstances.

Sounds like the patients would do well to see a certified disability analyst to make it clear whether or not they meet the guidelines defining coverage under the ADAA http://www.insideadhd.org/Article.aspx?id=286

The guidelines used to be much more narrow but a series of court cases have been won over the past 6 years that broadened them. This may make it possible to appeal at least for some of the patients in question to win an appeal under the Disability and Discrimination Act.

PMRNC

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Re: ADHD and 2nd level appeals
« Reply #2 on: August 11, 2014, 11:34:12 PM »
Quote
I am surprised it wasn't allowed based on the parity rules. I think it would be worth a try, as ADHD is categorized as a disability protected by the ADAA under specific circumstances.

Sounds like the patients would do well to see a certified disability analyst to make it clear whether or not they meet the guidelines defining coverage under the ADAA http://www.insideadhd.org/Article.aspx?id=286

The guidelines used to be much more narrow but a series of court cases have been won over the past 6 years that broadened them. This may make it possible to appeal at least for some of the patients in question to win an appeal under the Disability and Discrimination Act.

This is going to be tricky.. we met with an attorney willing to take this on for this client but he's going to need the patient's cooperation as these are ERISA claims.
Thank you for the link.. I will keep you posted on how this goes. THESE policies actually EXCLUDE coverage for ADHD/ADD so again, this is going to be tricky.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

PMRNC

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Re: ADHD and 2nd level appeals
« Reply #3 on: August 12, 2014, 08:11:16 PM »
This is just an update.. I didn't really expect to get too many responses here ...   This providers attorney is going to let us know our next step but has said that we have a great shot .. there are four carriers involved all ERISA policies. People...if you don't know ERISA..LEARN about it because you have NO idea how ERISA differs from what you have already learned!!
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com