Out-of-Network Insurance Processing Review:
The Dorm has arranged for SJHIA to provide its clients (if desired) with assistance in the task of recovering expenses of treatment that may be payable by insurance. The Dorm does not participate in any medical or behavioral health networks. It is a private practice and treated by healthcare insurance companies as an out-of-network provider.
If a Dorm client has decided to utilize the services of SJHIA, The Dorm will connect you to an SJHIA representative who will collect your insurance information, perform verification of benefits, and, with your consent, will begin to file claims on your behalf. SJHIA will follow up with your insurance company from filing to adjudication of your claims. You must sign an authorization allowing The Dorm to release information to SJHIA.
The healthcare insurance company is instructed to send payment directly to you along with an explanation of benefits (EOB) that explains the methods, policy, and rates they used to calculate a claim reimbursement.
Clients of The Dorm are asked to forward any and all insurance communication for services rendered by The Dorm to SJHIA. This includes an explanation of benefits, checks, medical records requests, etc. This will help SJHIA assist with timely and accurate adjudication of claims.
There is no fee to clients of The Dorm for the aforementioned services.
Who is SJ Health Insurance Advocates?
SJ Health Insurance Advocates, LLC (SJHIA) is a New Jersey-based company that specializes in behavioral health insurance authorization and claims management. The Dorm has arranged for us to help clients obtain reimbursement for treatment if you wish.
Subject to authorization by the client and agreement by the financial sponsor, SJHIA will work with the financial sponsor to verify insurance benefits and communicate to the financial sponsor such information as to whether the client has coverage for treatment, whether such coverage includes out-of-network providers, plan deductible, and out-of-pocket limits.
With the client’s authorization, The Dorm will provide all required information to SJHIA in order to utilize insurance benefits. In turn, SJHIA will verify and communicate to the client such information as to whether the client has coverage for treatment, whether such coverage includes out-of-network providers, plan deductible, and out-of-pocket limits.
Will SJHIA answer my questions about insurance benefits and authorizations?
SJHIA will provide answers to the many questions that arise regarding insurance benefits, along with advice on what approach will best serve you. To contact SJHIA, please call: (973) 740-0023 ext.# 110. Tell them that you are calling about The Dorm.
What level of care will SJHIA submit claims for?
SJHIA will file claims for the therapeutic component of the program at The Dorm which the insurance industry recognizes as reimbursable expenses. This includes Group Therapy, Family Therapy, Individual Therapy, and Nutritional Counseling.
Please be aware, insurance plans reimburse a maximum of one Group Therapy session per day, one Family Therapy session per day, one Individual Therapy session per day, and one Nutritional Counseling session per day. *Therefore, the claims that SJHIA files on your behalf, will often NOT add up to the full cost of your Treatment Tier at The Dorm.*
If requested and authorized by the client, SJHIA will request from The Dorm records of services rendered every Monday, capturing the previous week of services.
Prior to the initial claim submission, SJHIA will contact your insurance carrier to obtain authorization to file for such claims. After receiving authorization, SJHIA will submit your first claims 7-10 days after the start of treatment.
When can I expect to receive payment for services?
The Dorm is an out-of-network provider. As such, claims can take approximately 30 – 45 days to process, with often a longer turnaround time for the first set of claims submitted.
It is also important to note that insurance companies may request additional information from SJHIA and The Dorm before processing claims. This may include requesting medical records for review. This process may result in a delayed processing time and/or a decision to not pay out the claim. If this is the case, SJHIA will communicate that information to you.
Is there a way to determine how much money I will receive back if claims are approved?
SJHIA can provide some guidance around your reimbursement based upon your specific policy and the typically allowed amounts. Please see the following schedule of expected allowed amounts by service: