A free tool for people looking for treatment

Insurance call script for rehab.

Call the member services or behavioral health number on your insurance card and ask, in order: who manages your substance use benefit, which levels of care are covered, whether the program is in network, whether you need prior authorization, and what you'll pay for each day. Write down every answer, the rep's name and a reference number. Then call the program and check the same facts from their side. Fill in the script below on screen, or print it blank and use a pen.

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Insurance call script for substance use treatment

Person getting treatment Member ID Plan name Number I called Program Program's address Program's NPI or tax ID ask the program Level of care

Part 1: Calling your health plan

Say: "Hi, I'm calling to check my benefits for substance use disorder treatment. My member ID is ___. I'd like to check coverage for a level of care at a treatment program."

Do you manage my substance use benefits, or does a separate behavioral health company? If it's separate, what's their name and number?
Some plans hand mental health and substance use care to another company (a "carve-out") with its own network and approvals. If so, ask them the rest of these questions.
Is my coverage active? When does my plan year start over?
Your deductible and out-of-pocket maximum reset at the start of each plan year.
Which levels of substance use treatment does my plan cover: detox, residential, PHP, IOP, outpatient counseling?
Is the program in network for this level of care, at this address?
Give the program's name, address and NPI or tax ID so the rep looks up the right location. A program can be in network at one site, or for one level, and not another.
If it's out of network, do I have out-of-network benefits? What's my out-of-network deductible, coinsurance and out-of-pocket maximum?
HMO and EPO plans usually cover only in-network care except emergencies. Out of network, the program can also bill you the difference between its charge and what the plan pays.
Does this level of care need prior authorization? Who asks for it, the program or me? How many days does an approval usually cover before a review?
Preauthorization is the plan's OK before you get a service. It isn't a promise the plan will pay, and each level usually needs its own approval, so ask again before a step down from residential to PHP or IOP.
What will I pay for each day: a copay, coinsurance, or both? Does the deductible apply first?
Ask for each level you might use. Residential is usually an inpatient benefit; PHP and IOP are usually outpatient.
How much of my deductible is left this year? How much of my out-of-pocket maximum? For me, and for the family?
The out-of-pocket maximum left is the most you'd pay this plan year for covered in-network care. These two numbers, with the cost per day, are what the rehab cost calculator needs.
Is there a limit on days or visits?
Under the federal parity law, day and visit limits for substance use care can't be stricter than for comparable medical care.
Are medications for alcohol or opioid use disorder covered? Under my medical or my pharmacy benefit?
Can you send me the medical necessity criteria you use to approve this level of care?
Under the parity law, a plan must make its medical necessity criteria for mental health and substance use benefits available to you on request, and give the reason if it denies a claim.

Before you hang up, say: "Can I read that back to make sure I have it right?" Then ask for the call reference number.

Rep's name Date and time Reference number

Part 2: Calling the program

Say: "Hi, I'm looking into treatment for myself (or a family member). I have my insurance, and I'd like to know what to expect."

Are you in network with my plan for this level of care? Will you verify my benefits and ask my plan for any prior authorization?
Many programs check benefits for you. Compare their answers with what your plan told you, and ask about anything that doesn't match.
How do you decide which level of care I need? Is there an assessment first, and is it free?
What's the schedule: how many days a week, how many hours a day, and about how many weeks?
What does my plan allow you for a day of this level? If I pay myself, what's your daily rate, and do you have a sliding-scale fee?
If you pay yourself, or don't use insurance, you have a right to a written Good Faith Estimate before you start.
Is anything billed separately, such as doctor visits, lab tests or medication?
If my plan stops approving days, what happens next? Do you offer the next level down, such as PHP or IOP after residential?
When is the next opening? What do I bring on the first day?

Who I spoke with Date and time Their direct number

Notes

From gocimahealth.com/tools/insurance-call-script-for-rehab. General information, not insurance or legal advice.

Before you call

Your insurance card. Your member ID, and the phone numbers on the back. A separate "behavioral health" or "mental health and substance use" number usually means a different company manages this benefit.
The program's details. Its name, the address where you'd go, and its NPI (National Provider Identifier) or tax ID. The program can give you these, and they help the rep find the right location in the network.
The level of care. Detox, residential, PHP, IOP or outpatient. If you don't know yet, ask about each one; the program decides which fits after an assessment.
Time and a pen. Calls can take a while. If you're calling for someone else, the plan may need that person on the line to give permission first.

Why each answer matters

Ask about	Why
Who manages the benefit	A behavioral health carve-out has its own network and approves care itself, so its answers are the ones that count.
Network	In network, the program accepts your plan's rate and your out-of-pocket maximum caps your share. Out of network you may owe much more, or everything, depending on your plan type.
Prior authorization	Residential, detox and PHP usually need it, and IOP often does. Without it the plan can refuse to pay. Approval still isn't a promise to pay.
Cost per day	Programs bill by the day, so your copay or coinsurance for a day, times the days you attend, is most of what you'll pay.
Deductible and out-of-pocket left	They're shared with your medical care for the year, so they decide how much of the cost is yours first, and the most you can owe.
Medical necessity criteria	Plans approve care that's medically necessary. Knowing the criteria up front helps if the plan later says no.
The reference number	If a claim is later denied, it's your record of what you were told and when.

The rules behind the questions

Preauthorization isn't a promise. HealthCare.gov defines it as your plan's decision that a service is medically necessary, which some plans need before you get it, except in an emergency. It isn't a promise the plan will cover the cost.
Parity. The federal Mental Health Parity and Addiction Equity Act says that when a plan covers substance use treatment, its copays, deductibles, day limits and approval rules can't be stricter than for comparable medical and surgical care. Deductibles and out-of-pocket maximums count both together.
Your right to the criteria. Under the parity rules, the plan must make its medical necessity criteria for mental health and substance use benefits available on request, and give you the reason for any denial. The U.S. Department of Labor's consumer guide explains these rights and how to ask.
Carve-outs. Parity law allows a plan to hand this benefit to a separate company, but the benefit still can't be managed more strictly than medical care.
Texas Medicaid. Members don't pay copays. Detox and residential treatment need prior authorization, and Texas Medicaid considers a request sent within 3 business days after admission. Call the member services number on your health plan's card to find in-network programs.
Paying yourself. Under the No Surprises Act, a provider must give an uninsured or self-pay patient a written Good Faith Estimate.

If the answers don't match, or the plan says no

Call back with your reference number and ask the plan to check again, or ask the program to call the plan with you on the line.
Ask for a denial in writing, with the reason and the criteria used.
Appeal. File an internal appeal with the plan, then ask for an independent external review if needed. Urgent cases move faster. Step by step: if your plan says no.
Get free help. The Texas Department of Insurance Help Line, 800-252-3439, for plans it regulates; the U.S. Department of Labor, 1-866-444-3272, for employer plans; and the Texas HHS Ombudsman, 800-252-8154, for Medicaid and CHIP behavioral health.

Next steps

Rehab cost calculator: put your answers in and see your share for IOP, PHP and residential.
Does insurance cover rehab? What each kind of coverage pays for in Texas.
IOP vs PHP cost in Texas, by coverage.
Texas treatment programs by insurance plan.
Behavioral health carve-outs and the rest of our guide to using insurance in Texas.

If you need help now: call 911 in an emergency. In a mental health or substance use crisis, call or text 988, any time. SAMHSA's National Helpline, 1-800-662-4357, is free, confidential and open 24/7, including for people without insurance.

Questions

What should I ask my insurance about rehab?

Who manages your substance use benefit, which levels of care are covered, whether the program is in network, whether you need prior authorization and who requests it, what you pay a day, how much of your deductible and out-of-pocket maximum is left, any limit on days, and whether medication is covered. Write down the rep's name and a reference number.

Can the rehab program call my insurance for me?

Yes, many programs verify your benefits and request prior authorization themselves. It's still worth calling your plan yourself, so you hear the answers first-hand and have your own reference number.

Can I call my family member's insurance for them?

The plan may ask for the member's permission before it talks to you about their coverage. Call together if you can, with the member on the line.

What is a behavioral health carve-out?

A plan that hands its mental health and substance use benefit to a separate company. That company has its own network and approves care, so ask it, not the medical plan, about networks and approvals. The clue is a separate behavioral health number on your card.

Does prior authorization mean my plan will pay?

No. It means the plan agreed the care is medically necessary before you got it. The plan can still review the claim, and it usually approves intensive care in blocks of days and reviews progress before approving more.

Is what I type saved anywhere?

No. The boxes are in your browser only; nothing is sent or saved. Print or save the page as a PDF before you close it if you want to keep your answers.

Sources

HealthCare.gov: Preauthorization and Medically necessary
HealthCare.gov: Plan and network types (HMO, EPO, PPO)
U.S. Department of Labor: Making the most of your mental health and substance use disorder benefits (your right to the plan's criteria and reasons)
eCFR: 29 CFR 2590.712, parity in mental health and substance use disorder benefits (disclosure of medical necessity criteria and reasons for denial)
CMS: The Mental Health Parity and Addiction Equity Act
HealthCare.gov: How to appeal an insurance company decision
Texas Department of Insurance: Get help with an insurance complaint
TMHP: Texas Medicaid Provider Procedures Manual, Behavioral Health (substance use prior authorization)
Texas HHSC: Summary of Texas parity findings (no Medicaid copays)
Texas HHS Office of the Ombudsman: Behavioral health help
CMS: Your rights under the No Surprises Act (Good Faith Estimates)

General information, not insurance, legal or medical advice. Your plan's documents decide what's covered.