Residential Rehab

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.

An Explanation of Benefits is a health-plan statement showing how an addiction-treatment claim was processed, including billed charges, allowed amount, insurer payment, and patient responsibility. It is not a bill.

An ERISA health plan is generally an employer-sponsored benefit plan governed by federal ERISA rules. ERISA can affect rehab claims, appeals, plan-document rights, and which agency regulates a coverage dispute.

The Mental Health Parity and Addiction Equity Act requires many health plans that cover mental health and substance use disorder care to apply financial requirements and treatment limitations no more restrictively than comparable medical and surgical benefits.

Harm reduction uses practical, evidence-informed strategies to reduce overdose, infection, and other harms while keeping people connected to health care and creating pathways into addiction treatment when they are ready.

Fentanyl test strips are drug-checking tools that can detect fentanyl in many drug samples. They can reduce uncertainty but cannot tell how much fentanyl is present or guarantee that a sample is safe.