Residential Rehab

A Good Faith Estimate is an estimate of expected charges that certain providers must give people who are uninsured or not using insurance, subject to federal No Surprises Act rules.

An out-of-pocket maximum is the most you generally have to pay in a plan year for covered in-network services before the health plan pays 100% of covered benefits for the rest of that year.

Balance billing happens when a provider bills a patient for the difference between its charge and the amount an insurer allows or pays, subject to network contracts and applicable federal or state protections.

An insurer can stop authorizing a higher level of addiction care and approve a lower level instead, but that coverage decision is distinct from the treatment team’s clinical recommendation.

If insurance authorization ends before treatment is complete, the treatment team can review the denial, submit additional clinical information, appeal when appropriate, or plan a clinically appropriate transition in care.

An insurance case manager may review treatment needs, coordinate benefits and authorizations, and communicate with providers during rehab, but does not replace the treatment team.

A medical necessity review evaluates whether a requested addiction treatment service or level of care is clinically appropriate and meets an insurance plan’s coverage criteria.

Concurrent review is an insurance or utilization-management review that occurs while residential rehab is underway to determine whether continued care at that level remains medically necessary.

Utilization review is the process of evaluating whether addiction treatment is medically necessary, appropriate for the current level of care, and consistent with benefit requirements.

ASAM levels are clinical intensity standards, while detox, residential, PHP, and IOP are common treatment labels that may correspond to different parts of the care continuum.