Understanding Mental Health Insurance Coverage
Learn your rights under federal parity laws, what mental health services are covered, and how to navigate your behavioral health benefits.
Mental health insurance coverage has improved significantly over the past decade thanks to federal parity laws that require insurers to treat mental health benefits on equal footing with medical and surgical care. Despite these protections, navigating mental health benefits can still feel confusing.
This guide will help you understand your rights, decode your mental health benefits, identify what services are typically covered, and know when to advocate for yourself if your plan isn't meeting its legal obligations.
Mental Health Parity – Your Rights
Understanding the federal law that protects your access to mental health care
What Is the Mental Health Parity and Addiction Equity Act (MHPAEA)?
The Mental Health Parity and Addiction Equity Act (MHPAEA) is a federal law passed in 2008 that requires most health insurance plans to cover mental health and substance use disorder (MH/SUD) services in a way that's equal to how they cover medical and surgical care.
In practical terms, parity means your insurance company cannot place stricter limits or higher costs on mental health services compared to physical health services.
What Parity Covers
MHPAEA applies to three main areas where insurers might try to restrict mental health coverage more than medical coverage:
1. Financial Requirements
Copays, coinsurance, and deductibles for mental health services must be comparable to those for medical care. If your plan charges a $25 copay for primary care visits, it generally can't charge $50 for therapy sessions.
2. Treatment Limitations
Visit limits, day limits, or other quantitative restrictions on mental health services can't be more restrictive than those on medical services. For example, if your plan doesn't limit how many times you can see a cardiologist, it can't cap therapy visits at 20 per year.
3. Non-Quantitative Treatment Limitations (NQTLs)
These are plan policies that aren't expressed as numbers but still restrict access—like prior authorization, medical necessity criteria, formulary design, network adequacy, and reimbursement rates. These policies must be applied no more stringently to mental health than to medical care.
Important: Under the Consolidated Appropriations Act of 2021, plans must prepare detailed "comparative analyses" showing that each NQTL applied to mental health is comparable to how it's applied to medical/surgical care. Plans must provide these analyses to regulators on request.
What Parity Does NOT Require
It's important to understand that:
- • Parity doesn't require coverage. If a plan doesn't offer mental health benefits at all (rare—most plans must under the ACA), parity doesn't apply.
- • Parity applies when MH/SUD benefits are offered. Once they are, they must be treated equally.
- • Not all plans are subject to MHPAEA. Self-funded church plans and plans with fewer than 50 employees may be exempt.
2024 Final Rule and 2025 Enforcement Status
In September 2024, federal agencies issued a strengthened MHPAEA Final Rule that required plans to collect and analyze outcomes data (like denial rates and network adequacy) to demonstrate parity. However, following litigation filed by the ERISA Industry Committee (ERIC) in January 2025, federal agencies announced they would not enforce the new 2024 Rule provisions while reconsidering them.
What this means for you: Your basic parity rights under the original MHPAEA statute, 2013 regulations, and the CAA 2021 comparative analysis requirement remain fully in effect. Federal and state agencies continue to enforce parity using these existing tools. If you believe your plan is treating mental health benefits unfairly, your rights to file complaints and appeals are unchanged.
How to Identify Parity Violations
Watch for these red flags that may indicate your plan is not compliant:
- • Higher copays or coinsurance for therapy compared to specialist visits for physical health
- • Arbitrary caps on therapy visits (e.g., "20 sessions per year") when no similar cap exists for physical health visits
- • Requiring prior authorization for mental health services but not for comparable medical services
- • Significantly smaller provider networks for behavioral health than for medical providers
- • Denying coverage for medically necessary mental health treatment while routinely covering equivalent medical treatment
Where to Report Parity Violations
If you believe your plan is violating mental health parity protections, you can file a complaint with:
- • Your State Insurance Department – Most states have consumer assistance programs for fully insured plans. In Maryland, the Maryland Insurance Administration (MIA) actively enforces parity laws and has recovered over $42 million for consumers through investigations in 2025 alone.
- • U.S. Department of Labor (DOL) – For employer-sponsored health plans (ERISA plans). File online or call 1-866-444-3272
- • Centers for Medicare & Medicaid Services (CMS) – For marketplace plans purchased through HealthCare.gov
- • State Attorney General's Office – Some states have enforcement authority for parity laws
Request a Parity Analysis
Under federal rules, you have the right to request detailed information about how your plan applies coverage limitations to mental health versus medical benefits. This is called a comparative analysis. If you suspect a parity violation, ask your insurer (in writing) to provide this analysis. They are required to provide it within 30 days.
What Mental Health Services Are Typically Covered
Common services, CPT codes, and what 'medically necessary' means
Most health insurance plans that include mental health benefits cover a range of outpatient and intensive services. The specifics vary by plan, but here are the most commonly covered mental health services:
Outpatient Therapy Services
- • Individual psychotherapy – One-on-one therapy sessions (most common)
- • Group therapy – Therapy with multiple patients, led by a licensed provider
- • Family therapy – Sessions involving family members to address relational dynamics
- • Couples therapy – Some plans cover this if related to a diagnosed mental health condition; many exclude it
Psychiatric and Assessment Services
- • Psychiatric evaluations – Comprehensive assessments by psychiatrists
- • Medication management – Follow-up visits for psychiatric medications
- • Psychological testing and assessment – Diagnostic assessments for ADHD, learning disabilities, autism, etc.
Intensive and Higher Levels of Care
- • Intensive outpatient programs (IOP) – Typically 9+ hours per week of structured treatment
- • Partial hospitalization programs (PHP) – 20+ hours per week, more intensive than IOP
- • Inpatient psychiatric hospitalization – Short-term acute care for stabilization
- • Residential treatment – 24/7 care in a non-hospital setting (coverage varies widely)
Telehealth / Virtual Therapy
Most plans now cover telehealth for mental health services, including audio-video and (in some cases) audio-only sessions. We cover this in detail in the Telehealth and Virtual Therapy Coverage section below.
Common CPT Codes for Therapy
When your therapist bills insurance, they use CPT codes (Current Procedural Terminology codes) to identify the service provided. The most common codes for outpatient therapy are:
- • 90834 – Psychotherapy, 45 minutes (actual range: 38–52 minutes)
- • 90837 – Psychotherapy, 60 minutes (actual range: 53+ minutes)
- • 90847 – Family psychotherapy (with patient present)
- • 90853 – Group psychotherapy
- • 90791 – Psychiatric diagnostic evaluation (intake/assessment)
Your Explanation of Benefits (EOB) will list the CPT code billed for each session. Understanding these codes can help you verify that claims are processed correctly.
What Does "Medically Necessary" Mean for Mental Health?
For a mental health service to be covered, it must typically be deemed medically necessary. This means the service is appropriate to diagnose, treat, or manage a mental health condition based on accepted clinical standards.
Insurers evaluate medical necessity for mental health based on factors such as:
- • Diagnosis – Presence of a diagnosable mental health condition (DSM-5 diagnosis)
- • Symptom severity – How significantly symptoms impair daily functioning
- • Level of impairment – Impact on work, school, relationships, or safety
- • Treatment history – What's been tried before and current response to treatment
- • Risk factors – Safety concerns, self-harm risk, substance use, etc.
When Services May NOT Be Covered
Even if a service is beneficial, it may not be covered if it's considered:
- • Not medically necessary – For example, therapy for general life coaching, personal growth, or marital enrichment without a diagnosed condition
- • Excluded by the plan – Some plans specifically exclude couples therapy, court-ordered treatment, or certain types of assessments
- • Experimental or non-evidence-based – Treatments not supported by clinical research
Always check your plan's Summary of Benefits and Coverage (SBC) or Evidence of Coverage (EOC) document to see what's excluded.
Understanding Your Mental Health Benefits
How to decode the mental health-specific section of your insurance plan
When you review your insurance plan documents, you'll often find a section specifically dedicated to "Mental Health and Substance Use Disorder Services" or "Behavioral Health." Here's what to look for and what each term means:
Deductibles (Combined vs Separate)
Most modern plans use a combined deductible, meaning mental health expenses count toward the same deductible as medical expenses. However, some older or grandfathered plans may have a separate behavioral health deductible.
What to check: Look at your plan's schedule of benefits. If it lists separate deductibles for "Medical" and "Behavioral Health," you'll need to meet both. Under parity laws, most plans cannot impose separate deductibles unless they apply similar separation to medical/surgical services.
Copays and Coinsurance for Therapy
Your plan will specify what you pay per therapy session. This is typically structured as:
- • Copay – A fixed dollar amount (e.g., $30 or $40 per session)
- • Coinsurance – A percentage of the allowed amount (e.g., 20% of the negotiated rate)
Mental health visits are usually classified as specialist visits, so your copay will often match what you'd pay to see any other specialist (cardiologist, dermatologist, etc.). Under parity, your mental health copay should not be higher than your specialist copay.
Out-of-Pocket Maximums
Your out-of-pocket maximum is the most you'll pay for covered services in a plan year. Once you reach this amount (through deductibles, copays, and coinsurance), the plan covers 100% of covered services for the rest of the year.
Mental health expenses always count toward your out-of-pocket max. If your plan tries to exclude mental health expenses from this cap, that's a parity violation.
Session Limits and Annual Maximums
Under MHPAEA, insurers cannot impose arbitrary visit limits on mental health services unless they apply comparable limits to medical/surgical care. For example:
- • If your plan caps therapy at 20 visits per year but doesn't limit cardiology or orthopedic visits, that's likely a parity violation
- • If your plan limits all outpatient specialist visits (medical and mental health) to 30 per year, that's generally compliant
Watch for "soft caps": Instead of upfront visit limits, many plans now use "soft caps" where claims are automatically approved for a certain number of sessions (typically 20-30 per year), after which the plan triggers a concurrent review. Your provider must then submit a treatment update or engage in a peer review to justify continued care. While this isn't technically a "hard cap," it can effectively limit access if not applied equally to comparable medical services.
Watch Out for Hidden Limits
Some plans use medical necessity reviews or concurrent authorization processes that effectively limit mental health visits even if there's no explicit cap. If your plan routinely approves ongoing medical treatment but requires you to re-justify therapy every 6–10 sessions, that may be a parity issue.
How to Find Your Mental Health Benefits
To understand your specific mental health coverage:
- 1. Review your Summary of Benefits and Coverage (SBC) – This is a standardized document that outlines your coverage in plain language
- 2. Check your Evidence of Coverage (EOC) or Summary Plan Description (SPD) – These are the detailed plan documents
- 3. Call Member Services – Use the number on your insurance card and ask specifically about outpatient mental health coverage
- 4. Use our verification guide – Visit our Verify Your Benefits page for a step-by-step checklist
Behavioral Health Carve-Outs
What they are, how to identify them, and why they matter
What Is a Behavioral Health Carve-Out?
A behavioral health carve-out means your mental health and substance use disorder benefits are administered by a separate company from your main medical insurance. While your medical claims go through your primary insurer (e.g., Aetna, CareFirst, UnitedHealthcare), your mental health claims are processed by a specialized behavioral health company.
This is extremely common in employer-sponsored health plans, and it's important to know if your plan has a carve-out because it affects:
- • Where you verify benefits
- • Which provider directory to use
- • Who to call for prior authorization
- • Where to file appeals for denied claims
Common Behavioral Health Carve-Out Companies
The following companies frequently manage behavioral health benefits on behalf of major insurers:
- • Carelon Behavioral Health (formerly Beacon Health Options)
- • Optum Behavioral Health (part of UnitedHealthcare)
- • Magellan Health
- • Lyra Health
- • ComPsych
- • ValueOptions
How to Know If Your Plan Has a Carve-Out
Here's how to identify a behavioral health carve-out:
1. Check Your Insurance Card
Look for a separate phone number labeled "Behavioral Health," "Mental Health," or "EAP" (Employee Assistance Program). If there's a dedicated number, you likely have a carve-out.
2. Call Your Main Insurance Company
Call the Member Services number on your card and ask: "Are my mental health benefits carved out to another company?" They'll tell you if a third party manages your behavioral health coverage.
3. Review Your Plan Documents
Your Summary Plan Description (SPD) or Evidence of Coverage (EOC) will indicate if behavioral health is administered by a separate entity.
Implications of a Carve-Out
When your mental health benefits are carved out, keep these considerations in mind:
- • Provider networks may differ. Your medical in-network provider list won't necessarily match your behavioral health network. Always verify mental health network status separately.
- • You'll need to contact the carve-out company to verify benefits, find providers, request authorizations, and appeal denials related to mental health services.
- • Claims go to different places. Your therapist will bill the behavioral health company, not your primary insurer.
- • Benefits tracking may be separate. Deductibles and out-of-pocket maximums typically combine across your medical and behavioral coverage, but you may need to check with both companies to get your full claims history.
Finding In-Network Therapists with a Carve-Out
If your plan has a behavioral health carve-out, use the carve-out company's provider directory, not your main insurer's directory. For example, if you have Aetna but your behavioral health is managed by Carelon, search Carelon's provider directory at plan.carelonbehavioralhealth.com/find-a-provider/.
Prior Authorization for Therapy
What it is, when it's required, and how to navigate the process
What Is Prior Authorization?
Prior authorization (also called preauthorization, precertification, or pre-approval) is a process where your insurance company requires approval before you receive certain services. The insurer reviews clinical information to determine whether the service is medically necessary and covered under your plan.
If prior authorization is required and not obtained, the insurance company may deny the claim or reduce payment—even if the service is otherwise covered.
When Is Prior Authorization Required for Mental Health Services?
Prior authorization requirements vary by plan. Common scenarios where it's required include:
- • Intensive outpatient programs (IOP) or partial hospitalization programs (PHP)
- • Inpatient psychiatric hospitalization
- • Psychological or neuropsychological testing
- • Transcranial magnetic stimulation (TMS) or other specialized treatments
- • Ongoing outpatient therapy beyond a certain number of sessions (some plans require periodic reauthorization)
Important: Most plans do not require prior authorization for standard outpatient therapy (individual, family, or group therapy sessions). However, some do—always verify with your insurer.
How to Obtain Prior Authorization
In most cases, your provider initiates the prior authorization process, not you. Here's how it typically works:
- 1. Your provider contacts your insurance (or the behavioral health carve-out company) to request authorization.
- 2. The provider submits clinical information— including diagnosis, treatment plan, symptom severity, and medical necessity justification.
- 3. The insurer reviews the request and issues a decision, typically within 5–14 days (urgent requests are reviewed faster).
- 4. You and your provider receive notification of approval, denial, or a request for more information.
What Happens If You Don't Get Prior Auth When Required
If your plan requires prior authorization for a service and it isn't obtained before you receive care, the claim may be denied entirely—leaving you responsible for the full cost. Always verify whether prior auth is needed before starting treatment, especially for intensive services or testing.
Concurrent Review and Continued Stay Authorization
Some plans use concurrent review, meaning they periodically reassess whether ongoing treatment remains medically necessary. This is most common for:
- • Inpatient psychiatric stays
- • Residential treatment programs
- • Intensive outpatient or partial hospitalization
- • Long-term outpatient therapy (e.g., after 20–30 sessions, the plan may require reauthorization)
Your provider will handle concurrent review requests, but you should be aware of these checkpoints. If authorization is denied at a review stage, you have the right to appeal.
What to Do If Prior Authorization Is Denied
If your insurer denies prior authorization:
- 1. Request a detailed explanation of why the request was denied.
- 2. Ask your provider to submit additional clinical information or clarify medical necessity.
- 3. File an appeal if you believe the denial is incorrect. Your plan must provide an appeals process. You or your provider can submit additional documentation supporting medical necessity.
- 4. Request an external review if your internal appeal is denied. An independent reviewer (not employed by your insurer) will evaluate the case.
Parity and Prior Authorization
Under mental health parity laws, insurers cannot apply prior authorization requirements more stringently to mental health than to medical/surgical services. If your plan routinely approves ongoing physical therapy without frequent reauthorization but requires you to re-justify therapy every 10 sessions, that may be a parity violation worth reporting.
Telehealth and Virtual Therapy Coverage
Understanding insurance coverage for remote mental health services
Telehealth coverage for mental health services has expanded significantly in recent years, especially since the COVID-19 pandemic. Most insurers now cover virtual therapy sessions, but the specifics vary by plan type and state.
Current State of Telehealth Coverage
As of 2025, telehealth mental health coverage generally depends on your insurance type:
- • Private commercial insurance: Most plans cover telehealth for mental health, with coverage protections in states that have enacted telehealth parity laws (over 40 states).
- • Medicare: Mental health telehealth services, including audio-only, have been made permanent for behavioral health (through at least 2026).
- • Medicaid: Varies by state. Most states cover telehealth mental health services; check your state Medicaid agency for specifics.
- • Employer-sponsored plans: Coverage depends on the plan design. Some have scaled back telehealth coverage for non-behavioral health services but retained it for mental health.
Telehealth Parity Requirements
Many states have enacted telehealth parity laws, which generally require that:
- • Services delivered via telehealth are covered on the same basis as in-person services
- • Cost-sharing (copays, deductibles) for telehealth cannot exceed that for in-person care
- • Insurers cannot impose additional restrictions (like requiring prior authorization for telehealth but not in-person visits)
As of 2025, 22 states have full payment parity, 6 states have parity with caveats, and 22 states have no payment parity requirement.
In-State vs Out-of-State Providers
For telehealth therapy to be covered, the provider generally must be:
- • Licensed in your state (the state where you're physically located during the session)
- • In-network with your insurance plan
Some insurers will cover out-of-network telehealth providers, but you'll typically pay higher out-of-network cost-sharing. Always verify network status before starting telehealth therapy.
Audio-Only vs Video Sessions
Coverage for audio-only therapy (phone sessions) varies:
- • Medicare: Covers audio-only for mental health services permanently, as long as the provider is capable of video but the patient prefers or cannot access video.
- • Private insurance: Many plans have scaled back coverage for audio-only sessions. Some cover it only if the beneficiary cannot access video (lack of technology or broadband). State laws vary.
- • Check with your specific plan before scheduling audio-only sessions.
Verify Telehealth Coverage Before Starting
Before beginning telehealth therapy, confirm the following with your insurance:
- • Does your plan cover telehealth for outpatient mental health services?
- • Is the cost-sharing the same as in-person visits, or different?
- • Does your plan cover audio-only sessions, or only audio-video?
- • Is the provider you're considering in-network for telehealth services?
How COVID Expanded Telehealth Coverage
During the COVID-19 Public Health Emergency (PHE), federal and state governments temporarily expanded telehealth coverage. Many of these flexibilities have been made permanent or extended, especially for mental health services:
- • Medicare permanently covers audio-video and audio-only mental health telehealth
- • Most private insurers added or expanded telehealth coverage during COVID and have largely kept it for behavioral health
- • Many states enacted permanent telehealth parity laws during or after the pandemic
However, some insurers are scaling back coverage for non-mental health telehealth services. Always verify your current plan's telehealth policies.
Maryland Residents: Strong Telehealth Protections
If you live in Maryland, you have some of the strongest telehealth protections in the country:
- • Preserve Telehealth Access Act of 2025 (HB 869/SB 372): Makes permanent that telehealth includes audio-only visits and requires payment parity—insurers must pay therapists the same rate for phone sessions as for in-person visits.
- • Access to Nonparticipating Providers (HB 11/SB 902): If you cannot find an in-network therapist within a reasonable time and distance, your insurer must provide a referral to an out-of-network provider at in-network cost-sharing. You cannot be charged more than your regular copay.
- • If your Maryland-regulated plan denies audio-only therapy or refuses an out-of-network referral when the network is inadequate, file a complaint with the Maryland Insurance Administration—these protections are legally enforceable.
In-Network vs Out-of-Network for Therapy
How network status affects your mental health care costs
Whether your therapist is in-network or out-of-network with your insurance plan significantly impacts your out-of-pocket costs. While we cover this topic in detail on our Out-of-Network Benefits page, here's a quick overview specific to mental health services:
| Aspect | In-Network | Out-of-Network |
|---|---|---|
| Your cost per session | Lower (e.g., $30 copay or 20% coinsurance) | Higher (e.g., 50% coinsurance + potential balance billing) |
| Provider rates | Negotiated/contracted rate (lower) | Therapist's full fee (often higher) |
| Claim filing | Provider files claims | You may need to file claims and get reimbursed |
| Balance billing | Not allowed | Provider can bill you for the difference between their fee and what insurance pays |
| Plan coverage | All plan types cover | HMO and EPO plans often provide no coverage (except emergencies) |
Finding In-Network Mental Health Providers
To find therapists who are in-network with your plan:
- 1. Check your insurer's provider directory online (or call Member Services)
- 2. If you have a behavioral health carve-out, use that company's directory (not your main insurer's)
- 3. Filter by specialty (psychologist, LCSW, LCPC, etc.) and location
- 4. Verify directly with the provider before your first session—directories are often outdated
When Out-of-Network Might Make Sense
Despite higher costs, some patients choose out-of-network therapists because:
- • Limited in-network options in their area or for their specific needs
- • Established therapeutic relationship with a therapist who isn't in-network
- • Need for specialized treatment not available in-network
- • Privacy concerns about insurance knowing their diagnosis
If you're considering an out-of-network provider, verify your out-of-network benefits first and understand what you'll pay per session. Learn more about out-of-network coverage →
Network Adequacy and Parity
Under mental health parity laws, insurers must maintain adequate networks of mental health providers. If your plan's behavioral health network is significantly smaller or less accessible than its medical network, that may be a parity violation. If you cannot find an in-network therapist within a reasonable distance or timeframe, you may be able to request a network gap exception—allowing you to see an out-of-network provider at in-network rates.
Common Coverage Challenges
Issues patients frequently encounter and how to address them
Even with strong federal parity protections, patients often face obstacles when trying to access mental health benefits. Here are the most common challenges and what you can do about them:
1. Session Limits and "Soft Caps"
The problem: Despite parity laws, some plans still cap therapy at a certain number of visits per year (e.g., 20 or 30 sessions), while others use "soft caps" where automatic approval ends after a set number of sessions, triggering mandatory review.
What to do: Ask your insurer: "Do you impose similar visit limits on other outpatient specialty care, like cardiology or physical therapy?" If they don't, the mental health cap is likely a parity violation. File a complaint with the Department of Labor, your state insurance department, or CMS.
1A. The "90837 Audit Pressure"
The problem: Some insurers, particularly Optum and UnitedHealthcare, have implemented systematic audits targeting providers who frequently bill CPT code 90837 (60-minute sessions) rather than 90834 (45-minute sessions). Providers who bill 90837 for more than a certain percentage of their sessions may receive warning letters or be placed on "pre-payment review," creating a chilling effect that effectively shortens therapy sessions.
What to know: This is an administrative limitation rather than an explicit coverage denial. If your therapist suddenly switches to shorter sessions citing "insurance requirements," this may be why. If you believe longer sessions are clinically necessary for your treatment, discuss this with your provider and consider whether the plan applies similar scrutiny to extended medical appointments.
2. Medical Necessity Denials
The problem: Your insurer denies coverage claiming therapy is not "medically necessary," even though you have a diagnosed condition and your provider recommends treatment.
What to do:
- • Request the clinical criteria the insurer used to make the decision
- • Ask your provider to submit additional documentation supporting medical necessity
- • File an internal appeal, then an external review if the internal appeal is denied
- • If denials are routine but comparable medical treatments are approved, consider whether this is a parity issue
3. Provider Network Adequacy Issues
The problem: Your plan's behavioral health network is so small that you can't find an in-network therapist accepting new patients, or no providers are within a reasonable distance.
What to do:
- • Request a network gap exception (also called a single-case agreement) that allows you to see an out-of-network provider at in-network rates
- • Document your search efforts (providers contacted, wait times, distances)
- • File a complaint if the network is inadequate—network adequacy is a parity requirement
4. Prior Authorization Delays
The problem: Your insurer takes weeks to approve prior authorization for intensive treatment, delaying care when you need it most.
What to do:
- • Request an expedited review if the delay could seriously jeopardize your health
- • Ask your provider to submit supporting documentation emphasizing urgency
- • If your plan routinely delays mental health authorizations but approves medical authorizations quickly, this may be a parity issue
5. Diagnosis Requirements and Stigma
The problem: To receive coverage, you must have a formal mental health diagnosis on file, which some patients find stigmatizing or worry could affect future coverage or employment.
What to know:
- • Insurance companies require a diagnosis to determine medical necessity—this is standard across both mental and physical health care
- • Your diagnosis is protected health information under HIPAA and cannot be disclosed without your consent
- • Genetic Information Nondiscrimination Act (GINA) and ACA protections prevent health insurers from using mental health diagnoses to deny coverage or increase premiums
- • If privacy is a major concern, some patients choose to pay out-of-pocket (self-pay) to avoid insurance involvement entirely
6. How to Appeal Coverage Issues
If your claim is denied or your benefits seem insufficient, you have the right to appeal:
- 1. File an internal appeal with your insurance company (this is required before external review)
- 2. Submit supporting documentation from your provider
- 3. Request an external review if your internal appeal is denied—an independent reviewer will evaluate your case
- 4. File a complaint with the Department of Labor, your state insurance department, or CMS if you believe parity laws are being violated
Common Denial Codes and What They Mean
When your claim is denied, you'll receive an Explanation of Benefits (EOB) with a denial code. Here are the most common:
- • CO-50 (Medical Necessity): The insurer believes the service isn't medically necessary. Often cited for "lack of progress" or "maintenance care." Request a peer-to-peer review where your provider can explain your case to the insurance company's doctor.
- • CO-16 (Missing/Invalid Information): Usually a paperwork error, such as a missing telehealth modifier (GT or 95). Your provider should correct and resubmit.
- • CO-29 (Filing Limit Expired): The claim was submitted too late (typically after 90-180 days). This is usually a provider billing issue, not your responsibility.
- • CO-197 (Prior Authorization Absent): Prior authorization was required but not obtained. Request retroactive authorization if the service was urgent, or file an appeal explaining why authorization wasn't feasible.
Don't Give Up on Your Benefits
Mental health coverage is your right under federal law. If you're facing barriers to care, don't assume you've run out of options. Many denials are overturned on appeal, and parity complaints can lead to systemic changes that improve coverage for everyone. Advocate for yourself, and don't hesitate to seek help from a patient advocate or mental health organization if you need support navigating the process.
Questions to Ask About Your Mental Health Benefits
Essential questions to get clear answers from your insurance company
When verifying your mental health coverage, ask these specific questions to get a complete picture of your benefits:
1. Are my mental health benefits carved out to another company?
What answer to expect: Yes/No, and if yes, the name of the behavioral health company and their contact information.
2. What is my copay or coinsurance for outpatient therapy?
What answer to expect: A specific dollar amount (copay) or percentage (coinsurance), and whether this applies before or after your deductible.
3. Do I have a deductible that applies to mental health services?
What answer to expect: Yes/No, the deductible amount, and whether it's combined with medical or separate for behavioral health.
4. Is there a limit on the number of therapy sessions I can have per year?
What answer to expect: Most plans should say no limit, or "subject to medical necessity review." If they cite a hard cap (e.g., 20 visits), ask whether similar caps apply to other outpatient specialty care.
Red flag: A specific session cap that doesn't apply to comparable medical care may be a parity violation.
5. Do I need prior authorization for outpatient therapy?
What answer to expect: Most plans do not require prior auth for standard outpatient therapy, but some do. If yes, ask at what point it's required (e.g., after 10 sessions).
6. Is [specific provider name] in-network for my plan?
What answer to expect: Yes/No. If you have a carve-out, make sure you're checking with the behavioral health company, not just your main insurer.
7. Does my plan cover telehealth therapy? Is the cost-sharing the same as in-person?
What answer to expect: Yes/No on coverage, and whether copay or coinsurance is the same for telehealth vs in-person visits.
8. Do I have out-of-network benefits for mental health services?
What answer to expect: Yes/No, and if yes, what the coinsurance percentage is and whether there's a separate out-of-network deductible.
9. How much have I paid toward my deductible and out-of-pocket max so far this year?
What answer to expect: Specific dollar amounts for both, which helps you estimate your costs for the rest of the plan year.
10. What is the process if I need to appeal a denied claim?
What answer to expect: Instructions on how to file an internal appeal, the timeline, and information about external review options.
Document Everything
When calling your insurance company, take notes: write down the date, time, representative's name, and what they told you. Request a reference number for the call. If you later face a denial or billing issue, this documentation can be invaluable when filing an appeal or complaint.