There are many reasons why insurance may be marked as ineligible after our team's review. In the event this happens, Alma will send you an email explaining the reason, as well as next steps if we can make updates.
If you’ve been marked ineligible and would like to continue therapy without insurance coverage, we recommend reviewing our Support Center article How to Pay for Therapy Without Insurance Coverage.
Here are the most common reasons your insurance may be marked ineligible:
You have insurance that Alma does not currently accept
Alma is contracted with several national and regional participating plans, including Optum, Aetna, Cigna, and Anthem Blue Cross and Blue Shield.
You may have a health plan under one of these network partners, but the specific plan is managed by a third party administrator that Alma is not operationally set up to accept. If this situation applies, or if your plan is not managed by one of our network partners, your plan will be marked ineligible. See the list of payers accepted through Alma's insurance program.
You have a health plan administered by Medicaid or Medicare
Alma does not currently accept Medicaid or Medicare. This includes plans that are managed by commercial insurance, such as community/state plans and Medicare Advantage.
Your health plan hasn’t started yet
All insurance policies have an “effective date.” This is the date on which coverage becomes active. Often, payers do not display benefits for a policy that hasn’t kicked in yet.
If we receive insurance details attached to a policy with a future effective date, we will mark your insurance status ineligible until the policy’s effective date.
Your health plan has ended
If your policy has ended, this means you no longer have active coverage under that insurance policy for any dates of service after the termination date given by the health plan.
If you believe you have active coverage through another policy that is in-network with Alma's insurance program, please contact your provider about updating your insurance details.
A claim has been denied by your insurance payer
After your provider submits a claim through the Alma portal, your insurance payer will process it and ultimately determine if it will be covered or denied under your specific plan.
If the insurance payer denies a claim, Alma’s system will automatically mark the insurance as ineligible to prevent additional claims from being submitted and potentially denied. This gives our team the chance to investigate and determine the unknown reason the claim was denied so that we can work with your insurance carrier to resolve it. While we work to resolve the denial, we also recommend calling your insurance carrier for more details.
When a claim is denied, Alma automatically emails you about why that claim was denied. This email also includes a link for you to update your insurance details to rectify the issue that caused the denial.
You can find more information on how Alma supports clients when a claim is denied here: Why Some Insurance Claims Get Denied.
You need prior authorization in order for services to be covered in-network
“Prior authorization” means that your provider must get approval from your health plan before offering services in order for them to be covered by insurance. We see requirements for prior authorization most often around psychological testing.
You can also contact your health plan by calling the number on the back of your insurance card to get more information about prior authorization requirements.
Your insurance plan has limitations
Many insurance plans have specific limitations such as a benefit maximum for a certain numer of visits, referral requirements, or restrictions on the number of virtual visits allowed. Some limitations like referral requirements can be worked around, while others, like visit limits, cannot.
Sometimes you must obtain written confirmation to see a certain provider in-network. Unlike prior authorization, a referral is issued by another provider — either your primary care provider, or (if they have a student plan) a provider at their school’s health center.
If we see that your plan requires a referral, we will call your insurance company to determine whether you have a referral on file for mental health services. If you do not, we will mark your plan ineligible.
To get a referral, please reach out to your primary care provider and then contact us via our Support Request Form to let us know when the referral has been issued. Once we confirm that the referral has been uploaded to your health plan’s portal, we will complete an updated eligibility check. Learn more about insurance referrals.
Our team isn’t able to locate an active health plan with the details you provided
If the Alma team cannot identify an insurance policy that matches the insurance details that you provided, we will mark you ineligible. If possible, we will add a note letting you know which piece of information we suspect may be incorrect.
In these scenarios, it almost always helps our team if you or your provider can upload your insurance card, which often allows us to verify the details added to our portal. You can find more information about updating insurance details here: Adding Your Insurance Details to the Alma Portal.
The insurance details submitted are for your secondary insurance
In cases where a client has two or more health plans, coordination of benefits is the process insurance companies use to determine which is the primary plan — the plan responsible for covering the client’s claims first.
All other plans are called “secondary.” The client may be able to submit for additional reimbursement to these plans after the primary plan has processed their claims.
Alma is not yet set up to accept secondary insurance. If we determine that the insurance details you submit correspond to your secondary insurance, we will mark you ineligible. If you have a primary policy that may be in-network with Alma’s Insurance Program, please add those details to the portal so we can run an updated eligibility check.
Your health plan requires coordination of benefits
If your client has multiple insurance policies with multiple insurance companies, the insurance company will often request that your client designate one of these policies as primary before processing any claims.
We will mark your client as ineligible while they complete coordination of benefits with their health plans. Learn more about coordination of benefits.