Nivellark · U.S. patient guide

When mental health or substance-use treatment is denied

A coverage denial can make it harder to focus on care. You do not have to sort through every document at once. Start with the notice, confirm the process for your specific coverage, and ask your treating professional and plan what information is needed.

Official sources reviewed October 25, 2026

If waiting could affect your health

If a delay could seriously affect your health, tell your treating professional and contact the plan promptly to ask whether expedited review is available and how to request it. An appeal process is not emergency care; seek urgent help through your usual emergency-care options when needed.

First, identify your coverage

The right process depends on your plan

Before you send anything, confirm the procedures for your coverage with the plan administrator, insurer, or government program that issued the notice. Your denial letter, current plan documents, member handbook, or Summary Plan Description (SPD) should identify the starting point. State rules and the type of plan can change which office oversees the coverage and which review steps are available.

One step at a time

Practical next steps after a denial

  1. Start with the denial notice

    Keep the full denial notice and Explanation of Benefits (EOB), if you received one. Identify the service or level of care, dates, claim or authorization number, the decision date, and the exact reason given.

    Notice whether the plan describes a medical-necessity decision, prior-authorization issue, benefit exclusion, network issue, missing information, or billing or coding problem. The reason affects what records may help. A denial by itself does not establish that the plan violated parity rules.

    • Mark the appeal deadline and submission instructions stated in your notice.
    • If the reason is unclear, ask the plan to explain it and identify the plan provision or criteria it used.

  2. Confirm which appeal process applies to your plan

    Appeal steps, deadlines, reviewers, and external-review options can vary by coverage type and state. Use the denial notice and your current plan materials as the starting point, then confirm the instructions with the plan or program that issued the decision.

    Ask for the exact deadline, required form, delivery method, address or portal, whether more than one internal review is required, how to request expedited review, and whether an external review may be available. Do not assume a deadline or process from another plan applies to yours.

    • For employer coverage, check the Summary Plan Description (SPD) and ask the plan administrator or benefits office whether the plan is fully insured or self-funded.
    • For an individual or Marketplace plan, use the insurer’s appeal instructions and ask your state insurance department which consumer-assistance or review process applies.
    • For Medicare, Medicaid, or CHIP, follow the program-specific notice and member materials; their appeal paths differ from many commercial plans.

  3. Ask what information the plan relied on

    For a mental-health or substance-use denial, ask how the plan applied its medical-necessity or level-of-care criteria and what records it reviewed. You can ask the plan for the criteria and relevant decision information; what you can request and how it is provided may depend on the plan and applicable rules.

    If the decision involved prior authorization, concurrent review, provider-network access, or treatment limits, ask the plan to explain the rule it applied and where that rule appears in your coverage materials. Federal mental-health parity protections can be relevant to some plans, but they do not guarantee that a particular service is covered or that a denial will be reversed.

    • Write down the name or department of the person you spoke with, the date, and any reference number.
    • Ask how to get copies of the plan provisions, clinical criteria, and records that can be shared with you.

  4. Gather records connected to this decision

    Use the denial reason to decide what is relevant. Your treating professional may be able to help identify records that explain the requested treatment, the care setting or level, and how the information responds to the plan’s stated reason.

    • The full denial notice, EOB, and any prior-authorization or concurrent-review decision.
    • Your insurance card details, claim or authorization number, service dates, provider, and any related bills or codes.
    • The relevant plan document: SPD for an employer plan, Summary of Benefits and Coverage, member handbook, certificate, or coverage policy.
    • Relevant treatment records or a supporting statement from your treating professional, if they agree it is appropriate to share.
    • The plan’s written criteria or records it relied on, if you can obtain them, and your notes from calls or messages.
    • Keep copies of what you submit and proof of submission, such as a confirmation showing when and how the plan received it.

  5. Prepare and send the internal appeal

    Follow the instructions in your own notice and plan materials. Identify the decision you are appealing, briefly explain what you believe the plan should review, and attach the relevant records. If your treating professional is involved, ask whether they can provide information that addresses the plan’s stated reason.

    If someone else will help communicate with the plan, ask whether a representative form or written authorization is required. Send the appeal using the plan’s stated method before its stated deadline, and keep a copy plus delivery or submission confirmation.

    • If the deadline is close or the instructions are unclear, contact the plan promptly and ask what can be submitted now and how to preserve your review rights.
    • If time could affect your health, separately ask how to request expedited review; do not assume the standard process is expedited.

  6. Read the response and confirm what comes next

    Keep the plan’s response with your other records. If the denial remains, read the entire notice for the next step, who handles it, and the deadline. Ask whether external review or another program-specific review is available for your decision.

    If you are unsure where to turn, the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) can help with many private-sector job-based plans. For other coverage, contact the program or state office named in your materials. Free consumer-assistance resources may also be available.

    • For many private-sector job-based plans, contact an EBSA Benefits Advisor at 1-866-444-3272.
    • For Medicare, use Medicare’s appeal instructions and contact SHIP for free local counseling.
    • For Medicaid or CHIP, check your state agency and plan notices for any next appeal or fair-hearing step.

Official sources

These federal sources explain general appeal steps, plan-specific information, and mental-health parity protections. Follow your own notice and current plan documents for deadlines and requirements.

For the broader health-plan denial process, see the general health-insurance appeal guide. For information about Nivellark’s administrative tools for denied-therapy cases, see denied-therapy case support.