NEDA TOOLKIT for Parents
Obtaining Insurance Benefits for Higher Levels of Care
Many of the issues discussed in the previous section will be relevant to treatment at any level of care, but more
intensive treatment often brings up separate issues. Before an insurance company will cover eating disorder
treatment, they will conduct a utilization review. A utilization review occurs when your insurance company reviews
the insured’s benefits to make sure that the services being requested are both covered and “medically necessary.”
A utilization review generally consists of several steps:
1. Precertification – After completing a face-to-
face assessment with the patient, the assess-
ing clinician will call the insurance company
to request authorization of services before
the patient begins treatment. The reviewers
generally ask for the five-axis diagnoses, height,
weight, recent behaviors, treatment history,
goals for treatment, and estimated length of
stay. A case manager (CM) is usually assigned
to the case during this initial call, several days
are usually authorized, and the next review is
scheduled. 2. Concurrent Review – Several days are usually
authorized at a time and the insurance
companies request scheduled clinical updates
in order to authorize additional days. These
updates and requests for additional days
are called concurrent reviews. They are
usually done with the same care manager
every time. The CM generally asks for the
following information: current weight, vitals,
lab/bloodwork results, behaviors/struggles,
progress in treatment (individual work, family
work, insight development, etc.), mood/
affect, participation/motivation, discharge
plan, coordination with outpatient team, and
estimated length of stay.
a) It is very important to explain this process
to the patient as some patients may be
overwhelmed when they initially hear that
their insurance company has authorized 5
or 6 days and they plan to be in treatment
for weeks or months.
3. Discharge Summary – Some insurance
companies request notification of the patient’s
discharge. The discharge summary usually
includes the following information: Five-Axis
diagnoses upon discharge (any changes?),
medications upon discharge, follow-up
appointments (names of providers, dates and
times of appointments), total number of days
used. This is usually a pretty quick call and it’s
not always required by insurance.
Other steps:
1. “Clinical Case Consultation” – Occasionally
reviewers need to consult with other clinicians
or doctors before determining how many days
they will authorize. This generally happens
after the patient has been in treatment for a
while, appears to meet the criteria for medical
necessity, but may be getting close to requiring
a “doc-to-doc” review. This is not a denial.
After consulting with either the clinical team
at the insurance company or with the treating
doctor at the facility/clinic, the reviewer will
call back with an authorization and usually a
few additional questions for the next review.
2. “Doc-to-Doc” or “Peer-to-Peer” Review –
Cases are usually sent for a “doc-to-doc” for
one of the following reasons:
a) The patient has been in treatment for long
enough that the reviewer is unable to
authorize additional days without involving
a doctor from the insurance company.
b) The patient does not clearly meet the
criteria for medical necessity and a doctor
must use his or her clinical expertise/
discretion to determine if the level of care
being requested is warranted.
c) If this happens, it is fairly indicative of
an upcoming denial within the next few
reviews. d) Although the insurance company may not
always honor the request, it is perfectly
acceptable (and recommended) to
specifically request for the reviewer to be a
doctor who specializes in eating disorders.
3. Appeal – If authorization is denied, a facility/
provider has the right to file an appeal and
conduct a review with a different doctor.
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