Joshua Rivera

COBRA can allow eligible workers and family members to continue the same job-based health plan after certain qualifying events, so addiction-treatment benefits may continue under the same plan rules if COBRA is elected and premiums are paid.

A formulary exception is a request asking a health plan to cover a prescribed addiction-treatment medication that is not normally covered or to waive a formulary restriction when medically necessary.

An expedited appeal is a faster review of an insurance denial when waiting for the standard appeal timeline could seriously jeopardize a person’s health, safety, or ability to regain maximum function.

A mental health parity comparative analysis is a written evaluation of how a health plan’s nonquantitative treatment limitations for mental health and substance use disorder benefits compare with those used for medical and surgical care.

An NQTL is a non-numeric rule or process—such as prior authorization, medical-necessity criteria, step therapy, or network standards—that can limit access to behavioral health benefits.

Prior authorization and precertification are closely related insurance processes used to review whether rehab services meet plan requirements before treatment begins, but terminology varies by insurer.

Network adequacy means a health plan has enough appropriate in-network providers and treatment options so members can reasonably access covered addiction treatment.

An external review is an independent review of a health plan’s final denial of addiction treatment, often available after internal appeals for denials involving medical necessity, level of care, or other clinical judgment.

A peer-to-peer review is a discussion between the treating clinician and a clinician representing the health plan about a denied or questioned addiction-treatment service, often to clarify medical necessity and clinical facts.

An adverse benefit determination is a health plan decision to deny, reduce, terminate, or fail to pay all or part of a requested rehab benefit. It should explain the reason and available appeal rights.