Health Insurance Coverage
Health insurance plans often provide limited benefits for psychiatric treatment. Few plans provide benefits that reimburse all expenses of long-term treatment at residential care programs like the Austen Riggs Center. Riggs is an out-of-network provider, does not contract with any insurance company and is not a Medicare or Medicaid provider. Please carefully review the outline of responsibilities below:
Your Responsibilities – You are your own best advocate.
- Know your policy’s benefits and limits, including whether your plan covers residential treatment for behavioral health problems.
- Provide the admissions office with your plan’s criteria for determining medically necessary residential behavioral health treatment by asking your insurance company if preauthorization is required before they will approve admission to residential treatment.
- Ask your referring clinician to attempt preauthorization shortly before your scheduled admission consultation at Riggs.
- Manage the insurance appeals process if there have been two insurance denials of preauthorization. Note: it is your responsibility to: (1) provide your insurance company with a written request for an appeal; (2) sign a release for medical records to be sent to your insurance company; and (3) you may opt to request a letter of medical necessity from your therapist.
The admissions office staff may help you gather some of the above information.
Our Responsibilities – Within the best of our ability, we will:
- Request preauthorization (within 48 hours) from your insurance company after the initial admission consultation and subsequent admission to Riggs. We cannot request preauthorization if: (1) new insurance becomes effective during ongoing treatment, and/or (2) your policy has no out-of-network residential benefit.
- If preauthorization is approved, the admissions office will notify you in writing and will participate in ongoing utilization reviews as directed by your insurance company for as long as coverage is authorized during a patient’s stay.
- If preauthorization is denied, a doctor-to-doctor peer review with the insurance company will occur. If the peer review results in a second denial, Riggs will notify you in writing. At this point it is a patient’s responsibility to pursue any further appeal. If requested by you, Riggs staff can provide limited assistance in the appeals process, such as providing supporting documentation or medical record copies. Please note that we do not track the appeals process and are not notified of its outcome.
Note: When requested by you, Riggs will submit claims directly to the insurance company on behalf of the patient and/or financially responsible party, but this does not alter the requirement that accounts be kept current. Insurance payments received by Riggs are credited against a patient’s account. If there is a credit balance at discharge, the credit is returned to the financially responsible party.