Managed Care Letter
The intent of this letter is to explain how your insurance coverage applies to your child’s treatment at Meridell Achievement Center.
If you have an insurance plan that includes coverage for behavioral health residential treatment, admission and continued stay at Meridell Achievement Center is subject to your / your employer’s coverage policy and your insurers determination of medical necessity for treatment.
Your insurer might be Blue Cross & Blue Shield, Aetna, Cigna, United Health Care, ValueOptions or another company. If your insurer authorizes admission, they will specify the number of days they will initially approve. At admission, they often grant seven days, sometimes more, sometimes fewer. At the end of this initial period, Meridell will review your child’s progress with your insurer. This is called concurrent review and is completed by our Utilization Management Department.
If your insurer determines that your child meets their criteria for continued residential treatment, they will authorize more days. This review process will continue throughout your child’s stay at Meridell.
At some point in the utilization review process, your insurer may determine that your child no longer requires care at the residential treatment level of care. They may determine that your child is doing well enough to be discharged to a less intensive level of care such as outpatient care. If we believe that there is additional information that could change that determination, your insurer will schedule a peer review. During a peer review, your child’s psychiatrist at Meridell will review your child’s progress with your insurers psychiatrist. Based on this review, additional days may be authorized.
If additional days are not authorized, your insurer will deny additional payment for continued days of treatment at Meridell. If this occurs, an appeal may be filed with your insurer. You will be notified of your insurer’s decision to end their payment of your child’s treatment at Meridell.
Your child’s program therapist will discuss this with you, as will our Business Office. The therapist will advise you of the treatment team’s recommendations. The Business Office will advise you of the cost of continuing care privately.
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. You will be financially responsible for your child’s treatment at Meridell during the review process.
Your insurer might reconsider their denial. If this occurs, the denial is “overturned.” Your 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 your insurer’s denial is upheld, you will have two choices. Either your child can be discharged to continue treatment in outpatient care as recommended by the insurer, or you can continue your child’s treatment at Meridell with a private-pay arrangement.
You may disagree with your insurance company’s final determination and you have the right to challenge your insurers decision. At your request, we may be able to assist you. You can express your concerns to your employer’s benefits office and/or the Texas Department of Insurance.
The above information summarizes how insurance coverage applies at Meridell. We hope it gives you a better understanding and sets your expectations about residential treatment. Please do not hesitate to ask questions to help understand this process.
Ray Heckerman, CEO