Residential treatment centers (“RTC”) are live-in treatment facilities that offer comprehensive treatment options for a wide range of mental, substance abuse, and/or eating disorders. RTCs are often the next big step in a treatment plan when other available and more conservative treatments have failed.
Treatment at an RTC can be very costly. So, it is common for a person entering an RTC to submit a claim to their health insurance carrier to help cover the cost. Unfortunately, insurance companies do not always approve and pay these claims. Instead, insurance companies often deny these claims for one or more reasons
1. Your claim is most likely governed by a federal law known as ERISA.
Since most people obtain health insurance through their employer, these types of claims are often governed by a federal law called the Employee Retirement Income Security Act, or ERISA. However, your claim may also be governed by state law if you purchased your health insurance policy on your own.
Under ERISA, you have certain rights to protect yourself when filing a claim for RTC coverage. State insurance laws also give rights to policyholders. If your claim is denied, it is important to consult an attorney with experience handling RTC cases and fighting against wrong decisions by insurance companies.
2. Insurance companies commonly – and wrongly – deny RTC claims.
Most insurance companies will do everything they can to try to get out of paying for any service, including and especially costly RTC claims. This is true even when the service is covered by the policy and all paperwork has been properly submitted. While most RTC claim denials are due to lack of “medical necessity” or the use of an unapproved facility, other common reasons include:
- Lack of required pre-authorization
- Use of an out-of-network provider
- Service received was experimental
- Treatment was at a higher level of care than required
- Payment request was greater than the plan limits for the treatment
3. If your RTC claim is denied, you have the right to appeal within a limited time.
The plan of action to overturn a claim denial largely depends on the insurance company’s basis for not approving the request. When devising a successful appeal strategy, it is critically important to review and understand the terms of the policy, including the criteria for coverage approval and the deadline to challenge the insurance company’s denial.
Under ERISA, you also have certain rights to protect yourself when appealing the denial of an RTC claim.
Help from a Lawyer with Experience in Residential Treatment Center Claims
If you have any questions about RTC coverage, call our law firm to learn how we can help. It’s important to contact us before the final denial by the insurance company.
Call (800) 969-0488 for a free consultation with an experienced RTC attorney. Pay no fees or costs unless you get paid.
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