Why approval comes in pieces
Treatment needs change as someone moves through care. ASAM's Criteria are standards many programs use to decide where a person starts treatment, whether they continue at that level and when they move. ASAM says payers and managed care organizations should use the same criteria to decide what level of care they will cover, with the aim that people receive the least intensive care that is still safe and effective.
In practice, an insurer may approve an initial period and then ask the program for updated information before approving more. This is sometimes called concurrent review or utilization review. The program's staff send notes about how the person is doing, and the insurer decides whether the current level of care is still covered.
ASAM's Criteria FAQ also describes regular reassessment during treatment. For several outpatient and residential levels, it recommends formal reassessment monthly, and it notes that states can set their own rules on how often.
What an approval does and does not mean
An approval says the insurer has agreed to pay for a defined period or amount of care, under the terms of your plan. It does not guarantee payment for everything, and it does not decide how long you need treatment. HealthCare.gov explains that preauthorization is not a promise of payment.
A clinical recommendation and an insurance decision are separate. A care team can recommend more days than an insurer approves, or recommend moving to a lower level before the approval runs out.
Ask about approvals at the start
Before admission, or early on, ask the program how many days or sessions have been approved so far and when the next review is. Ask who at the program handles the insurer, and how you will be told about a decision.
Ask what usually happens at this program when an approval ends: whether people move to a less intensive level of care, whether care continues while an appeal is decided and whether self-pay is offered. Knowing the answer early lets you plan instead of reacting on short notice.
When the insurer says no more
If the insurer decides not to approve further care at the current level, ask the program to explain the decision and to share it in writing. Then ask three things. First, does the care team agree that the person is ready for a different level, or does it think more care is needed? Second, is the program appealing, and how long will that take? Third, what happens to care while the appeal is decided?
If the care team disagrees with the decision, ask whether a clinician has discussed it with the insurer and sent the information that would support continued care.
You can also contact the insurer yourself, using the member number on your card. Ask for the reason for the decision, what criteria were applied and how to appeal. Keep dates, names and reference numbers. HealthCare.gov describes how to appeal an insurance company decision, including internal appeals and external review.
Moving to a different level of care
Sometimes the end of an approval coincides with a planned step down, such as moving from residential care to an intensive outpatient program. If that is the recommendation, check that the next service has accepted you, that your insurance approves it and that the first appointment is booked before the current care ends.
If the move is happening because coverage stopped rather than because the team thinks you are ready, say so. Ask what extra support is available to make the transition safer.
Before you agree to pay yourself
A program may offer to continue care if you pay directly. Ask for the daily or weekly cost in writing, what is included and whether you can stop at any time without further charges. Ask whether paying yourself affects an appeal.
Do not agree to a payment plan or loan in a stressful moment without reading the terms. It is reasonable to ask for a day to decide, and to ask the care team whether a lower level of care would meet the need.
If you are the family member hearing about it
If you are supporting someone in treatment, the program may only share details about approvals if the person has given consent. You can still ask the person whether they would like help understanding the insurer's decision or making calls. Helping with the paperwork can be a practical way to support them without taking over their care.
Activities from this guide
Your checklist
Read the steps now. A free account lets you save your own checklist.
- 1. Ask how many days are approved and when review is
- 2. Ask for any denial in writing
- 3. Keep dates, names and reference numbers
About this guide
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Examples in this guide are illustrative, not reported experiences.
SoberSphere provides independent general information, not individual medical, legal or financial advice. No provider referral, affiliate arrangement or specialist review is claimed.