What Should You Ask After a Coverage Denial for Polysubstance Rehab in California?

Ask the insurer to identify the requested service or setting, requested dates, decision date, decision-maker, policy provision, clinical criteria, and factual basis. Request a copy of the criteria in effect on the date of review, not merely the name of a proprietary guideline. Ask which submitted records were considered and whether anything was missing, illegible, late, or sent to the wrong department.

Use a three-column page headed Confirmed, Needs review, and Not established. Under Confirmed, record only facts stated in documents, such as the denial date or appeal address. Under Needs review, list questions such as whether the insurer received a particular assessment. Under Not established, place assumptions including coverage, current availability, admission, clinical fit, room type, schedule, medication access, insurance participation, and outcome. This method keeps urgency from turning guesses into facts.

• Please send the complete denial notice and identify every reason for the decision.
• What exact benefit provision and review criteria were applied to this request?
• What service, setting, dates, and provider information did the reviewer evaluate? Is any of that information incorrect? Current provider participation must be confirmed directly, 


Copy each deadline exactly as printed and ask how it is calculated. Confirm whether the clock begins on the decision date, mailing date, receipt date, or another event. Ask where an appeal must be sent, what identifiers belong on it, which submission methods are accepted, and what counts as timely receipt. Request the expected review timeline and instructions for checking status.

Ask whether there is an internal appeal, an expedited process when applicable, an external review route, an employer-plan process, or a state or federal consumer-assistance channel. Which options apply depends on the plan and circumstances. Ask the insurer or plan administrator to identify the controlling process in writing. If the deadline is close, say so directly and ask what can be submitted now and supplemented later, but do not assume supplementation is permitted.

• What is the filing deadline, and exactly how is that deadline calculated?
• Which internal, expedited, external, employer-plan, or government review routes apply to this plan?
• Where should the appeal go, what must it contain, and how can receipt be confirmed?

Ask whether the insurer permits reconsideration, peer discussion, a corrected authorization request, or a new request based on new information. Use the insurer's exact terminology because these routes may have different rules and deadlines. Ask whether pursuing one route affects another. A representative's verbal answer should be noted, but request written instructions whenever available.

For alternate payment, ask the facility for a written estimate describing what is included, what may be billed separately, when payment is due, what happens if admission does not occur, and how refunds or balances are handled. Ask whether any financial-assistance or payment arrangements exist, but do not assume they do. Confirm whether choosing private payment could affect an appeal or later reimbursement request. The insurer and facility may need to answer different parts of that question.

• Can this decision be reconsidered or corrected without giving up any appeal right?
• What written estimate, deposit terms, cancellation terms, and refund terms apply?
• Could private payment affect appeal rights or possible reimbursement, and who can confirm that in writing?