National Eating Disorders Association

Determining how much coverage your loved one has can seem like figuring out a complicated series of math problems. By breaking the task down into simpler, more manageable tasks, you can get the job done so that your loved one gets the care they need and you don’t get overwhelmed.

  1. Obtain insurance info from patient. It is best to get a copy of the actual insurance card.
    • a) Name of insurance company
    • b) ID #
    • c) Group #
    • d) Phone number (often labeled “MH/SA” or “provider services” on back of card)
    • e) Subscriber’s name, date of birth, and relationship to patient (This is the policyholder’s info)
    • f) Employer (if it is a group policy)
    • g) Patient’s SSN and date of birth
    • h) Subscriber’s home address
  2. Call insurance company to verify benefits. It is best to record the call for future reference. Be sure to inform the other person you are recording. Verify the following:
    • a) Eligibility
      • i. Active policy?
      • ii. Effective date?
      • iii. Benefit year? This may be different than the calendar year and it will affect when the benefits renew.
    • b) Benefits
      • i. Does the member have benefits for the services he or she is requesting?
      • ii. What is the copayment or coinsurance for each type of service/level of care (check whatever is relevant)
      • iii. Is there a limit? If so, how many sessions have been used to date?
      • iv. Do the sessions cross-accumulate? (i.e. Do OP or IOP days accumulate towards total IP or PHP days allowed?)
    • c) Deductible and Out-of-Pocket (OOP) Maximum
      • i. What are the limits and how much of each has the patient met to date?
      • ii. Is the deductible included in the OOP max?
      • iii. Do copayments and coinsurance apply to the deductible and OOP max?
  3. Discuss benefits and estimated cost of treatment with patient.
  4. Keep track of benefit utilization throughout treatment and plan accordingly with patient.
  5. DOCUMENT all communication with the insurance company. It is amazing how many times records need to be produced in order for the claims to be paid accordingly.
    • a) Record phone calls if possible
    • b) Keep records of written correspondence (faxes, e-mails, etc.)
    • c) Document the date and time of a call as well as the name of the person you spoke with. Also ask for a reference number if possible.