Understanding Your Insurance

Understanding Your Insurance

Understanding Your Insurance

A major obstacle in accessing substance use and/or mental health treatment is understanding your insurance and the preauthorization process. Hopefully this little primer can help you get started! Whenever you call a treatment facility, often the first step is the verification of benefits.

The treatment facility will call your insurance company for you to verify if your insurance company will authorize treatment at that facility (provided you meet medical necessity). This does NOT mean that your insurance WILL cover your treatment – it only means that you are eligible for treatment at that facility provided you meet medical necessity. This means that a treatment facility cannot guarantee you a number of days of treatment upfront (if you are utilizing your insurance).

Once a treatment facility has verified your benefits, a team member will likely move forward in the process by asking you questions related to your current and past substance use history, past treatment, mental health condition; among other things. This is to assess for medical necessity. Medical necessity criteria is different for each insurance company – therefore an exhaustive list will not be entertained here; a general rule of thumb is if you require a medically monitored detoxification, are unable to function outside of 24 hour care, and/or have multiple major life impairments (legal, occupational, financial, relationship) that cannot be managed at a lower level of care – you will meet medical necessity criteria for admission. At this point, a senior clinician will review your case and determine if medical necessity is met. If you do not meet that general criteria, this staff member will recommend a lower level of care to you and will be able to offer you appropriate referrals.

If it is deemed that you do meet medical necessity, your admission will be arranged. Unfortunately, this process has only just begun! AToN Center only utilizes Licensed Clinical Psychologists for the Intake Assessment. You would then meet with one of these Psychologists who will complete a thorough interview. This interview will be utilized for treatment plan formulation, case conceptualization, discharge planning and insurance authorization. At this point, this Psychologist will then call your insurance company to review your past and present symptoms for preauthorization.

If the staff member at your insurance company agrees that you meet medical necessity, then they will authorize a certain number of treatment days (number of days varies based on the complexity of the symptoms). For example, if your insurance company authorizes six treatment days to start, then one of our psychologists would then call your insurance company on the sixth treatment day and review your current symptoms with an assigned case manager from your insurance company. This process continues throughout your treatment episode. As decisions about medical necessity can only be made based on current progress and symptoms of each resident, a guaranteed number of days by a treatment facility up front is dishonest.

AToN Center has qualified, seasoned and hard working Psychologists who strongly advocate for each of our residents daily. AToN Center also maintains high ethical standards, recommending the appropriate level of care based on the medical necessity of our residents. Hopefully this review answered some questions – as this is a complicated and confusing process! If you have any further questions, please feel free to comment below!

Cassandra Cannon, Ph.D.
Clinical Director
AToN Center  888-535-1516

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