Health insurance can be difficult to understand as insurance coverage and/or providers often change on a yearly basis. If your employer has recently taken on a new provider through open-enrollment, you surely have questions about what’s covered.
Hillside is happy to provide helpful information regarding mental health services in relation to insurance providers and coverage. Below is a listing of mental health insurance providers that we regularly work with and offer some type of mental health insurance coverage.
However, if you do not see your provider on this list, please contact us. We are constantly credentialing with new plans both commercial and Medicaid plans.
Also if we are not in-network with your plan, we can always work with you as an out-of-network provider. We have been successful in getting plans to agree to a Single Case Agreement to treat your child for this one stay as in-network providers. Most plans will agree to these Single Cases as we are currently the only Child and Adolescent Program in the Nation that has the Linehan DBT Certificate of Approval. We also work with families for private or self-pay situations.
Accepted Insurance Providers Offering Mental Health Coverage:
- BCBS Blue Cross Blue Shield
- Beacon Health Options (formerly “ValueOptions”)
- Beacon Health Options – Georgia Collaborative ASO
- CompCare/CBH Care – Comprehensive Behavioral Healthcare, Inc.
- Concentra Insurance/Principle Edge Network
- HealthOne Alliance/Alliant Health
- Humana/Humana One Health Plan of GA/Lifesynch – Humana Behavioral Health
- Kaiser Permanente
- Magellan Healthcare
- MHNet/Coventry Health Care
- MultiPlan/PHCS, Beech Street/Viant
- NEW! Tricare Humana Military Insurance/Tricare
- United Healthcare / United Behavioral Health (UBH) / Optum
Accepted Medicaid Insurance Providers Offering Mental Health Coverage:
- Amerigroup Georgia – GA Medicaid
- Beacon Health Options – Georgia Collaborative ASO
- Caresource – GA Medicaid
- Cenpatico – GA Medicaid
- Wellcare – GA Medicaid
- South Carolina Medicaid SC DHHS
- Tennessee Medicaid – Tenncare
Paying For Mental Health Care
If the insurance plan includes coverage for behavioral health Residential treatment, Day Programs or Partial Hospitalization, Intensive In-Home Therapy or Day Programs then coverage for admission and continued stay at Hillside is based on the insurance company’s guidelines for ‘medical necessity’ of treatment. Each covered service has to be pre-approved by your insurance company prior to delivery of services.
Each insurance provider and Medicaid coverage varies by state and/or plan. It’s best to consult with your provider to fully understand the coverage availabilities for mental health treatment. Each provider will typically outline their coverage availabilities on their website. If their mental health coverage is not outlined clearly or you do not fully understand the coverage, we recommend calling and speaking to a representative. On the back of your card there should be a number for behavioral health or mental health benefits that you may call. Our staff members are happy to assist with coverage questions as well.
Prior to an admission to any of our levels of care our Admissions Staff will check your benefits and determine what your responsibility is in terms of the percentage of coverage that the insurance will cover and what is your copayment, also your deductibles and how much of that you have met with other prior services or hospitalizations. To the best of our ability Admissions with pull together your financial responsibility with copays and deductibles and go over those with you. This financial responsibility on your part is due prior to services or mental health treatment is provided.
Understanding Health Insurance & What to Expect From Insurance Providers
If your insurer authorizes admission to Residential or Partial Hospitalization (Day Program), they will specify the number of days they will initially approve. Generally they authorize a short period of time initially, which prompts a clinical review shortly after admission so that the insurance company’s care manager can obtain information about our assessment of the patient’s condition and the patient’s initial response to treatment. For Partial Hospitalization Programs (PHP) or Day Programs, insurers may authorize an initial period of 1-3 days. For Residential Treatment, insurers often grant 5-7 days, sometimes more, sometimes fewer. At the end of this initial period, Hillside, Inc. will review the patient’s progress with the insurer. This is called “concurrent review” and is completed by our Utilization Management Department.
If the insurer determines that the patient meets their ‘medical necessity’ criteria for continued treatment, they will authorize coverage for an additional period of time. The review process will continue like this throughout the patient’s stay at Hillside, Inc.
For Residential Treatment and Partial Hospitalization (PHP), some plans specify a maximum number of days they will cover, provided that the patient continues to meet the ‘medical necessity’ or continuing stay criteria established by the insurance plan. We encourage parents to understand their insurer’s definition of medical necessity and any requirements the insurer has around family participation in treatment.
We will keep you updated on your child’s progress and will be working with you to coordinate a smooth transition home with needed support services. The care manager from the insurance company is often a great resource in identifying additional community-based services to ensure a successful transition. At some point in the utilization review process, the insurer may determine that the patient is no longer or close to no longer meeting their established criteria for inpatient or residential treatment. If this is the case we will notify you. If we believe that there is additional information that could change that determination, we will ask your insurer to schedule a “peer review.” During a peer review, the patient’s psychiatrist at Hillside will review the patient’s progress with the insurer’s psychiatrist. Based on this review, additional days may be authorized.
If additional days are not authorized, your insurer will deny payment for continued days of treatment at Hillside behavioral health facility. If this is the case, we will notify you as an appeal may be filed with your insurer. Our clinical staff will notify you of the denial and discuss the treatment team’s recommendations. If you wish to continue your child’s treatment at Hillside in spite of the insurance denial or during the appeal process, you will be referred to Admissions to discuss private-pay options.
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. Your insurer might reconsider their denial. If this occurs, the denial is “overturned.” The 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.
My Insurance Provider Isn’t Listed or Doesn’t Provide Coverage – What Else Can I Do?
If the insurer’s denial is “upheld”, you will have two choices. Either the patient can be discharged to continue treatment in outpatient care as recommended by the insurer, or you can continue the patient’s treatment at Hillside, Inc. with the private-pay arrangement.
You may disagree with your insurance company’s final determination and you have the right to challenge your insurer’s decision with your care manager. You can and should also express your concerns with your employer’s benefits office or human resources.
We hope this clarifies the often confusing trek thru Behavioral Health benefits and authorization for treatment. Please feel free to reach out to our Admissions staff prior to treatment and our Utilization Review staff during treatment with any concerns or questions.
If you do not see your provider on the above list, please contact us. We are constantly credentialing with new plans both commercial and Medicaid plans.
Insurance Assistance or Questions about Mental Health Coverage Through Insurance
Please contact one of our Admissions Coordinators about your coverage and any questions you have at 404-846-5118 ext. 205 for Michelle Kelley or ext. 339 for Chastity Banks. We are quite skilled at navigating your benefits and authorizations to maximize your coverage. Often if one level of care is not approved or a benefit, we can navigate your current benefits to see if we can access another level and have you match what is not covered to get the treatment your child or adolescent may need. If supplemental mental health insurance coverage is an option, these are areas we can explore as well.
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