Parity FAQ for Addiction and Mental Health Consumers

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West Virginia Parity Resources

Depending on whether you are filing a complaint or appeal, the contact information below should be able to help you if you have any questions.

 

Consumer Advocates


For general information about filing a parity appeal for mental health or addictions services, you cannot go wrong with contacting one of the consumer advocates below. Each has years of experience helping consumers in the state of West Virginia.

The Office of the Consumer Advocate Division
http://www.wvinsurance.gov/consumeradvocate.aspx

Guide to the External Review Process

Medicaid
Hotline for Assistance: 877-716-1212

Health Plan Contacts


When filing an appeal for the first time, you should contact your health plan’s customer service support line or check out their information online.

If you choose to appeal an adverse benefit determination concerning your mental health or substance use treatment or benefits, please keep in mind that the timeframe to do so varies by state, plan type, and other factors. Contact your state’s department of insurance for additional information.

Here is some contact information for West Virginia Health Plans:

Aetna

Call the Member Services number on the member ID card

Appeal request form is found here

Send form to:
Aetna
PO Box 14463
Lexington, KY 40512

To file online click here

CareSource

Call Member Services: 855-202-0622

To file a grievance send a letter to:
CareSource
Attention: West Virginia Member Appeals
PO Box 1947
Dayton, OH 45401

To file an appeal mail to:
CareSource
Attention: West Virginia Member Appeals
P.O. Box 1947
Dayton, OH 45401

Highmark Blue Cross Blue Shield

Call the Member Services number on the member ID card

West Virginia Family Health

Call Member Services: 855-412-8001

Send a letter to:
West Virginia Family Health
PO Box 22278
Pittsburgh, PA 15222

State Regulators


Insurance Commissioner

West Virginia Offices of the Insurance Commissioner
Commissioner
Mail:
P.O. Box 50540
Charleston, WV 25305-0540
Physical:
1124 Smith Street
Charleston, WV 25301
Toll Free: (888) 879-9842
Phone: (304) 558-3354
Fax: (304) 558-0412
health.policy@wvinsurance.gov

Utilization Management Appeals

Health Policy
Mail:
P.O. Box 50540
Charleston, WV 25305-0540
Physical:
1124 Smith Street
Charleston, WV 25301
Phone: (304) 558-6279
Fax: (304) 558-0412

External Review Appeals

West Virginia Offices of the Insurance Commissioner
Director, Health Policy
Mail:
P.O. Box 50540
Charleston, WV 25305-0540
Physical:
1124 Smith Street
Charleston, WV 25301
Phone: (304) 558-6279
Fax: (304) 558-0412

Parity Appeals

West Virginia Offices of the Insurance Commissioner
Director, Health Policy
Mail:
P.O. Box 50540
Charleston, WV 25305-0540
Physical:
1124 Smith Street
Charleston, WV 25301
Phone: (304) 558-6279
Fax: (304) 558-0412

Additional West Virginia Insurance Administration Contacts, click here.

Federal Regulators


The federal government also can be a helpful resource if you are enrolled in a self-funded plan, Medicare, Medicaid or another type of insurance that is overseen at least in part by a federal agency. For definitions and filing information refer to the Parity Resource Guide

U.S. Department of Health and Human Service’s website on the Affordable Care Act health reform law

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA)

(SAMHSA) Implementation Mental Health Parity Addiction Equity Act

U.S. Centers for Medicare and Medicaid Services (CMS) U.S. Department of Labor, Employee Benefits, Security Administration (EBSA) or toll-free hotline: 1.866.444.EBSA (3272)

For the U.S. Department of Health and Human Services & Centers for Medicare and Medicaid Services list of exempt state and local plans, please email NonFed@cms.hhs.gov. You may ask them if any particular state and local plan has opted out of MHPAEA.

Information on requirements of employer-based insurance coverage and self-insured health plans. EBSA has benefit advisors who are available to answer questions and provide assistance in obtaining your benefits.

Consumer Guide to Disclosure Rights: Making the Most of Your Mental Health and Substance Use Disorder Benefits

 

Veteran and Military Resources


Veterans and military personnel can use these resources to get help or more information with their medical or behavioral health complaints.

Health Net Federal Services

A grievance is a written complaint or concern about a medical provider.
Click here for specific information regarding who, what and how to file.

TRICARE

View the recently released Tricare Mental Health Fact Sheet.

The appeal process is different based on the benefit issue. Depending on your issue, you can file a:
  • Factual appeal
    • This is if you were denied payment for services or supplies you received, or if payment was stopped for services or supplies previously authorized.
  • Medical necessity appeal
    • This is if prior authorization for care or services was denied because it was not deemed medically necessary. Medically necessary means it must be appropriate, reasonable, and adequate for your condition.
  • Pharmacy appeal
    • This is if you don't agree with a decision made about your pharmacy benefit. For example, Express Scripts denies your pharmacy claim.
  • Medicare-TRICARE appeal
    • This is if you're eligible for both TRICARE and Medicare, and Medicare denies your services or supplies.

If your care is denied, you should receive a letter with details about how to file your appeal.

Veterans Health Administration

Complaints are initially handled through the Patient Advocate.
Patient Advocate can be contacted at your local VA Medical Center.

Questions


If you have any additional questions about parity compliance, please contact info@paritytrack.org