The intent of this section is to explain how private insurance coverage applies to the patient’s treatment at Laurel Heights Hospital behavioral health facility.
If the insurance plan includes coverage for behavioral health inpatient or residential treatment, insurance coverage for admission and continued stay at Laurel Heights is based on the insurance company’s guidelines for ‘medical necessity’ of treatment. These guidelines typically can be found on the insurance company’s web site.
Your insurer might be Blue Cross & Blue Shield, Aetna, Cigna, United Health Care, Value-Options or another company. Since each state’s Medicaid program is designed differently, we encourage all parents and/or guardians to contact Laurel Heights behavioral health facility to receive information on your Medicaid coverage regarding treatment.
Also, Laurel Heights serves military families by providing a TRICARE®-certified unit serving adolescent boys, ages 13-17. In addition to serving families from Georgia, we serve children of active duty and retired military families by making specialty arrangements for family participation. This unit provides treatment for teens who are struggling from a broad range of psychiatric and behavioral differences.
If your insurer authorizes admission, they will specify the number of days they will initially approve. Generally they authorize a short period of time initially, which prompts a clinical review shortly after admission so that the insurance company’s care manager can obtain information about our assessment of the patient’s condition and the patient’s initial response to treatment. For acute inpatient treatment, insurers may authorize an initial period of 1-3 days. For residential treatment, insurers often grant seven days, sometimes more, sometimes fewer. At the end of this initial period, Laurel Heights will review the patient’s progress with the insurer. This is called “concurrent review” and is completed by our Utilization Management Department.
If the insurer determines that the patient meets their ‘medical necessity’ criteria for continued treatment, they will authorize coverage for an additional period of time. The review process will continue like this throughout the patient’s stay at Laurel Heights.
For residential treatment, some plans specify a maximum number of days they will cover, provided that the patient continues to meet the ‘medical necessity’ or continuing stay criteria established by the insurance plan. We encourage parents to understand their insurer’s definition of medical necessity and any requirements the insurer has around family participation in treatment.
We will keep you updated on your child’s progress and will be working with you to coordinate a smooth transition home with needed support services. The care manager from the insurance company is often a great resource in identifying additional community-based services to ensure a successful transition. At some point in the utilization review process, the insurer may determine that the patient is no longer or close to no longer meeting their established criteria for inpatient or residential treatment. If this is the case we will notify you. If we believe that there is additional information that could change that determination, we will ask your insurer to schedule a “peer review.” During a peer review, the patient’s psychiatrist at Laurel Heights will review the patient’s progress with the insurer’s psychiatrist. Based on this review, additional days may be authorized.
If additional days are not authorized, your insurer will deny payment for continued days of treatment at Laurel Heights behavioral health facility. If this occurs, we will notify you as an appeal may be filed with your insurer. Our clinical staff will notify you of the denial and discuss the treatment team’s recommendations. If you wish to continue your child’s treatment at Laurel Heights in spite of the insurance denial or during the appeal process, you will be referred to the Business Office to discuss private-pay options.
The appeal process may go through several levels. It may take two to three days for each level of appeal, and up to 30 days for an independent review done by a psychiatrist independent of your insurer. Your insurer might reconsider their denial. If this occurs, the denial is “overturned.” The insurer will make payment for all the days previously denied and will specify how many more days of treatment will be authorized for payment. The concurrent review process will continue.
If the insurer’s denial is “upheld”, you will have two choices. Either the patient can be discharged to continue treatment in outpatient care as recommended by the insurer, or you can continue the patient’s treatment at Laurel Heights with the private-pay arrangement.
You may disagree with your insurance company’s final determination and you have the right to challenge your insurer’s decision. At your request, we may be able to assist you. You can also express your concerns to your employer’s benefits office.
We hope the above information gives you a better understanding of how your insurance works and sets your expectations about inpatient or residential treatment. Please do not hesitate to ask us for additional information.