Navigating insurance claims, appeals and getting appropriate insurance coverage for eating disorder treatments can be a challenging process. This section includes resources including letter templates, tips regarding appeals, fighting for coverage, and local mental health insurance information. If you have specific insurance questions or need help getting treatment coverage, we can help. Contact us at (408) 356-1212 for more details.

Read more from National Eating Disorders Association (NEDA): Insurance Resources

APA Level of Care Guidelines

Click here to view APA Level of Care Guidelines on the NEDA website.

Local Mental Health Insurance Referrals

County 60-Day Program

Phone: (408) 885-7855

 

 

Mental Health Advocacy Project (MHAP):

Address: 152 North Third Street, 3rd Floor, San Jose, CA 95112 (Across from Saint James Park on Third Street)
Intake line: (408) 280-2420 or (800) 248-6427
Fax: (408) 350-1158

MHAP is working on a statewide initiative to educate people about mental health parity laws. Parity laws require health insurance companies to provide equal coverage for physical health, mental health, and substance use disorders. MHAP’s goal is to provide trainings on the laws and parity protections. In some cases, MHAP can also provide direct representation for people who encounter problems with their insurance plans. Click here to view a flyer
and FAQ about the parity project.

 

MediCal and Managed Care MediCal:

Self-referral to County Mental Health Department: (800) 704-0900
Blue Cross Healthy Families Behavioral Health Programs: (800) 399-2421

 

Santa Clara Family Health Plan:

Address: 210 E. Hacienda Avenue, Campbell, CA 95008
Phone: (800) 260-2055

Santa Clara Family Health Plan is committed to providing quality, affordable health coverage to the uninsured and underinsured in Santa Clara County’s diverse communities. Medi-Cal coverage is free, while Healthy Families and Healthy Kids costs no more than $18 a month per family, depending on family income. As the designated community provider plan for Healthy Families in Santa Clara County, Santa Clara Family Health Plan offers these low rates for all the same benefits as the commercial plans. Santa Clara Family Health Plan is the exclusive plan to offer Healthy Kids benefits. Member benefits include comprehensive medical care such as preventive checkups, specialist care, a 24-hour nurse advice line, hospital care, prescriptions and many other services. Patients suffering from an eating disorder enter the system through this portal: https://www.sccgov.org/sites/bhd/Pages/home.aspx

 

Services for those with Medi-Cal

Santa Clara County Emergency Psychiatric Services (EPS):

Address: 871 Enborg Lane, San Jose, CA 95128
Phone: (408) 885-6100
Available 24-hours a day. Evaluation, assessment, treatment and observation, and referral to appropriate care, including admission to a hospital when needed.

 

Santa Clara County Mental Health Urgent Care:

Address: 871 Enborg Ct., San Jose, CA 95128
Phone: (408) 885-7855
Time: 8am-10pm daily; walk-in or by appointment
Walk-in outpatient clinic for Santa Clara County residents experiencing a mental health crisis. Provides screening, assessment, crisis intervention, referral and short-term treatment for adolescents and adults.

 

Santa Clara County Suicide and Crisis Hotline:

Phone: 1-855-278-4204
Time: 24-hours a day
Provides phone intervention and emotional support to individuals in crisis. Highly trained volunteer counselors assist people who are feeling suicidal, experiencing distress, or just need to talk with someone who will listen.

 

Santa Clara County Mental Health Call Center:

Phone: 1-800-704-0900
For information regarding behavioral and mental health services (including eating disorders), screenings, appointments, benefits and authorizations.

Insurance Coverage: Tips for Navigating

  • Eating disorders, particularly anorexia and bulimia, are usually covered by health insurance, partly as a result of the “parity law” now in effect in California, but figuring out exactly what the coverage is can be confusing. The parity law states that certain mental health disorders, including anorexia and bulimia, will have the same maximum co-payment as those in the general medical plan. This short guide will give you some basic information to help you get the benefits to which you are entitled and also to make decisions about maintaining insurance coverage for the future.
  • First, you should review and be aware of the details of your policy and contract. The major insurance companies vary tremendously as to what they will cover, and every insurance company has hundreds of different policies, each with its own coverage and terms. In addition, major insurance companies often have mental health benefits, under which eating disorders coverage falls, administered by a secondary company. The best way to be clear about your benefits and your payment responsibilities is to actually read all the information sent to you about your plan, as well as any updates. While reviewing all the specifics of your policy may seem like a daunting and unpalatable task, it is well worth the time since treatment of eating disorders can be very costly.
  • If you still have questions about your coverage after reviewing the policy, contact your health insurance company for further explanations. Ask to speak to the insurance company representative’s supervisor for further clarification if the answers you are given do not seem to fit with the terms of your policy as you understand it. You can also ask for help from your employer’s human resources department.
  • Remember that you are your own best advocate when dealing with your health insurance coverage issues. You should also be aware that all insurance companies have an appeal process whenever a claim is denied, and in some cases denials of coverage are overturned on appeal.
  • As the parent of a son or daughter with an eating disorder, you should keep in mind the issue of ongoing, long-term health insurance coverage. It is especially important that a person with any serious or pre-existing medical condition, which includes anyone with an eating disorder, never let health insurance coverage lapse. It is likely to be difficult and extremely expensive, if not impossible, to obtain or reinstate new insurance coverage. If your child’s insurance coverage is due to end because a parent changes jobs or is laid off, or because the child will pass the age under which they are covered, be sure to check with your health insurance company and your company’s human resources department to find out how coverage can be continued. You can also contact an insurance agent to find out what options you may have for health insurance, but be sure to explain fully your child’s medical history.
  • Again, make certain that you consider and settle this question before your child’s coverage ends, so that there will be continuous insurance coverage.
  • If you’re struggling to understand your insurance policy, Project HEAL provides an Insurance Navigation Program that can connect you with resource guides and insurance navigation specialists to help you understand your benefits and get you the appropriate treatment you need.

Insurance and Paying for Treatment

Contacting and working with insurance companies is an important, but sometimes challenging, aspect of the pre-treatment admission process. Eating Recovery Center’s website provides helpful information on financing eating disorder treatment and insurance coverage. Click here to read more.

How to Manage an Appeals Process

Click here to get more information from NEDA on managing an appeal.

In addition, the organization Families Empowered And Supporting Treatment for Eating Disorders (F.E.A.S.T.) published a guide describing the insurance appeal process. You can find it here.

Sample Letters to use with Insurance Companies

Click here to view sample letters from the NEDA website.

Strategies to Counteract Insurance Denials

Information from an insurance panel at NEDA conference with:

  • Attorney Lisa S. Kantor, Esq., of Kantor & Kantor LLP, Northridge, CA
  • Stacey Brown, Director of Nursing and Utilization Review
  • David Christian, Clinical Psychologist, Avalon Hills Eating Disorders Treatment Program

Common Reasons for Denial of Claims:

The panel outlined out three common reasons insurance claims are denied. The first reason involves the question of medical necessity. Parity laws require that mental health coverage be provided commensurate with medical health coverage. Second, medical stability will occur long before psychological stability. State definitions trump an insurer’s definition of medical necessity. Finally, clinicians should look for loopholes.

A second reason is exhaustion of benefits. To counteract this, clinicians, family, and patient should be very familiar with the individual policy because the company may deny benefits that are clearly included. It is also helpful to know the state’s degree of involvement with mental health parity laws, because the state may or may not participate in parity. A third reason for denial is rigidity about what the insurer thinks treatment be; for example, telephonic family treatment or partial treatment with boarding (one can legally bill for a lower level of care than what is being delivered). And, some companies attempt to selectively exclude eating disorder patients.