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How Insurance Determines Treatment Coverage

  • anonymous Asks ...

    My insurance company is giving me the run around, while attempting to get into inpatient dual-diagnosis rehab. They are not responding to the different facility who are attempting to get claims approved.

    Today I'm finally picking up my referral from an in-network psyc dr. for in patient rehab. What key elements need to occur for insurance companies to have no choice but to authorize treatment?

  • Dr. David Sack Says ...
    Dr. David Sack

    There are several factors related to meeting "medical necessity" for treatment:

    1. The amount/frequency of Drug/Alcohol  use and/or the need for a medically monitored detox
    2. Recent failure of treatment at a lower level of care (for example, outpatient treatment)
    3. The presence of a co occurring disorder such as diagnosed clinical depression or anxiety
    4. Medical problems and medication history
    5. Legal issues related to use
    6. Family or work problems related to use
    7. Employment that combined with substance abuse puts self or others in jeopardy, for example Nurse or Pilot. 

    Not all of these examples are required however your assessment must demonstrate the severity of your problem in order to meet the insurance companies criteria for residential treatment. 

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