Key Takeaways
- Pre-authorization is the process by which your insurer reviews and approves coverage for addiction treatment before it begins, typically required for residential and higher levels of care.
- Insurers use clinical criteria, usually based on ASAM guidelines, to determine whether the requested level of care is medically necessary for your specific situation.
- The pre-authorization process typically takes one to five business days for standard requests, with expedited reviews available within 24 to 72 hours for urgent situations.
- Concurrent reviews during treatment reassess medical necessity every three to seven days and determine whether continued coverage at the current level of care is authorized.
- Treatment centers handle most pre-authorization processes on behalf of patients, submitting clinical documentation and communicating with insurers throughout treatment.
What Is Pre-Authorization for Rehab?
Pre-authorization, also called prior authorization, is a process by which your insurance company reviews a proposed treatment plan and determines whether it will be covered before the treatment begins. For addiction treatment, pre-authorization is typically required for residential treatment, partial hospitalization programs, and sometimes intensive outpatient programs. Standard outpatient therapy generally does not require pre-authorization.
The purpose of pre-authorization is to verify that the proposed treatment is medically necessary, meaning it is the appropriate level of care for your clinical condition. Insurers want to ensure that patients receive the right level of care, neither too intensive for mild conditions nor too limited for severe ones. While the stated goal is appropriate care matching, pre-authorization also serves as a cost-management tool for insurers.
Understanding the pre-authorization process helps reduce anxiety about entering treatment and ensures that you and your treatment team take the necessary steps to secure coverage. Most treatment centers manage the pre-authorization process as part of their admissions workflow, but knowing what happens behind the scenes empowers you to advocate for yourself if challenges arise.
The Clinical Assessment: Foundation of Pre-Authorization
Every pre-authorization request begins with a clinical assessment, which is a comprehensive evaluation of your substance use history, current clinical condition, medical and psychiatric history, and psychosocial circumstances. This assessment provides the clinical foundation that your insurer uses to determine whether the requested level of care is medically necessary.
The assessment typically covers the severity and duration of substance use, past treatment history and outcomes, current withdrawal risk, co-occurring medical and psychiatric conditions, your living environment and support system, and your motivation and readiness for treatment. Each of these factors influences the level of care recommendation and the strength of the pre-authorization request.
ASAM Criteria and Level of Care Determination
Most insurers, and all California-regulated health plans under SB 855, use criteria based on the American Society of Addiction Medicine's multidimensional assessment framework to evaluate medical necessity. ASAM criteria assess patients across six dimensions: acute intoxication and withdrawal potential, biomedical conditions, emotional and behavioral conditions, readiness to change, relapse and continued use potential, and recovery environment.
Based on the assessment results across these dimensions, a level of care recommendation is generated. ASAM levels range from 0.5 (early intervention) through 4 (medically managed intensive inpatient). The pre-authorization request must demonstrate that the patient meets criteria for the requested level of care across the relevant ASAM dimensions.
Submitting the Pre-Authorization Request
Once the clinical assessment is complete, the treatment center submits a pre-authorization request to your insurer's utilization review department. This submission includes the clinical assessment, the recommended level of care, the proposed treatment plan, and any supporting documentation such as medical records, previous treatment records, and letters from referring providers.
Treatment centers experienced with insurance processes know what information each insurer prioritizes and how to present clinical information in a way that supports authorization. This expertise is valuable because the quality and completeness of the initial submission significantly affects the likelihood of approval. Incomplete or poorly organized submissions are more likely to be delayed or denied.
Trust SoCal's admissions team submits comprehensive pre-authorization requests that address all ASAM dimensions and anticipate the questions insurers typically raise. Our clinical team prepares detailed documentation that clearly demonstrates medical necessity and supports the requested level of care. This thorough approach results in faster approvals and fewer denials for our patients.
The quality of the initial pre-authorization submission significantly affects the outcome. Choose a treatment center with experience managing insurance authorizations to improve the likelihood of a smooth approval process.
The Insurer's Review Process
After receiving the pre-authorization request, the insurer's utilization review team evaluates the clinical information against their medical necessity criteria. This review is typically conducted by a nurse or clinical reviewer with behavioral health expertise. If the initial reviewer approves the request, authorization is granted. If the reviewer has concerns, the case may be escalated to a physician reviewer for further evaluation.
Standard Review Timeline
Standard pre-authorization reviews for addiction treatment typically take one to five business days. During this time, the insurer may request additional information from the treatment center, which can extend the timeline. California law requires health plans to make utilization review decisions within five business days for prospective reviews and within 72 hours for retrospective reviews.
Treatment centers can often continue the admissions process while authorization is pending, ensuring that administrative delays do not prevent patients from beginning treatment when they are ready. In many cases, a verbal authorization is obtained within 24 hours, allowing admission to proceed while formal written authorization follows.
Expedited Reviews for Urgent Cases
When a patient needs immediate treatment due to active withdrawal, suicidal ideation, or other urgent clinical circumstances, expedited pre-authorization reviews are available. Expedited reviews must be completed within 72 hours under federal regulations and within 24 hours for urgent cases under California law.
To trigger an expedited review, the treatment center documents the urgent nature of the clinical situation and communicates this to the insurer's utilization review team. The clinical documentation should clearly articulate the risks of delaying treatment, such as medical complications from unsupervised withdrawal, risk of self-harm, or progressive deterioration.
Concurrent Reviews During Treatment
Pre-authorization does not end at admission. Throughout your treatment, your insurer conducts concurrent reviews to reassess whether continued care at the current level remains medically necessary. Concurrent reviews are one of the most important and sometimes challenging aspects of the insurance process for addiction treatment.
During a concurrent review, your treatment center submits updated clinical information describing your progress, current clinical status, and ongoing treatment needs. The insurer evaluates this information to determine whether you continue to meet criteria for the current level of care. If the review supports continued treatment, authorization is extended for an additional period, typically three to seven days.
If a concurrent review determines that you no longer meet criteria for the current level of care, the insurer may authorize a step-down to a less intensive level, such as transitioning from residential to outpatient. This decision may or may not align with your treatment team's clinical judgment. If there is a disagreement, the treatment center can request a peer-to-peer review or file an appeal. Trust SoCal advocates for our patients during concurrent reviews, ensuring clinical documentation supports continued treatment when it is clinically warranted.
What to Do If Pre-Authorization Is Denied
A pre-authorization denial means the insurer has determined that the requested level of care is not medically necessary based on the submitted clinical information. This does not necessarily mean you do not need treatment; it may mean the insurer believes a different level of care is appropriate, or that the submitted documentation was insufficient to support the request.
If your pre-authorization is denied, your treatment center should immediately request a peer-to-peer review, where a clinician from the treatment center speaks directly with a physician at the insurance company to discuss the case. Peer-to-peer reviews are often successful because they allow clinicians to present nuanced information and answer specific questions about why the requested level of care is necessary.
If the peer-to-peer review does not result in authorization, a formal appeal can be filed. The appeal should include additional clinical documentation, a detailed letter of medical necessity from the treating clinician, and references to the specific ASAM criteria that support the requested level of care. In California, you also have the right to request an Independent Medical Review through the DMHC. Contact Trust SoCal at (949) 280-8360 for guidance on navigating pre-authorization challenges.
A pre-authorization denial is not the final word. Many denials are overturned through peer-to-peer reviews, formal appeals, and Independent Medical Reviews. Do not let a denial prevent you from pursuing the treatment you need.
Rachel Handa, Clinical Director
Clinical Director & Therapist
