Standards of Care – How to Appeal Denials of Coverage

Standards of Care for Behavioral Health Services

Standards of care, or level-of-care criteria, are guidelines by which mental health and substance use service providers, as well as insurers, determine the level of care an individual should receive for behavioral health treatment. It is not uncommon for an insurer’s care determination to be misaligned with the service provider’s expert opinion. The National Council for Mental Wellbeing is dedicated to bridging this gap in how generally accepted standards of care are understood and applied by payers and providers.

Recent Legal Action

On February 28, 2019, Judge Joseph Spero of the United States District Court for the Northern District of California issued the findings of fact and conclusions of law in Wit v United Behavioral Health (UBH), a class action brought against the country’s largest behavioral health insurer. In deciding the case, the court enunciated eight general standards of care applicable to service intensity/patient placement selection for behavioral health care and applied those standards to the guidelines and practices of UBH operations.

Members of the National Council’s Medical Director Institute (MDI) reviewed and discussed the eight standards as enunciated by the court and have issued a statement of their position on the issue.

Dr. Joseph Parks, MDI Co-chair, co-authored the article, Holding Insurers Accountable for Parity in Coverage of Mental Health Treatmentwhich further discusses the Wit case.

Dr. Parks also participated in a webinar titled “Game Changer: Implications of the Wit v. United Behavioral Health Ruling.” The purpose of the webinar was to learn more about current efforts to increase access to mental health care. The Mental Health & Suicide Prevention National Response to COVID-19 has issued six priorities for not only meeting current needs, but also emerging stronger and more resilient than we were before the pandemic. You can now access the webinar recording here (password: Qja7JvMd).

Sources of Generally Accepted Standards of Care

Generally accepted standards of care are those standards which are based on credible scientific evidence and generally recognized by behavioral health experts. Some sources of generally accepted standards of care are:

For more information, please contact Lindsi DeSorrento, Director of Healthcare Transformation at the National Council for Mental Wellbeing.