SJHIA and The Dorm

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.

The Dorm may connect you/your financial sponsor to an SJHIA representative to collect your insurance information, perform verification of benefits, and, with consent, will begin to file claims on your behalf. SJHIA will follow up with your insurance company from filing to adjudication of your claims. The primary member on the insurance plan must sign SJHIA’s Opt-in Form, agreeing to utilize SJHIA’s services.   The Dorm will provide information to SJHIA to allow SJHIA to perform tasks consistent with the above.

The healthcare insurance company is instructed to send payment directly to you/your financial sponsor 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. Given that reimbursement is directed to the Plan Subscriber it is imperative that clients send us all communication so that we can ensure accurate and timely 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 SJHIA to help clients obtain reimbursement for treatment if you wish.

Subject to agreement by the financial sponsor / the primary on the insurance plan, 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.

The Dorm will provide all required information to SJHIA in order to utilize insurance benefits. In turn, SJHIA will verify 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.

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 components of the program at The Dorm which the insurance industry generally 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 file claims for services mid-month one month in arrears. You can track the status of the claims by logging on to your insurance carrier’s member portal or by calling your insurance carrier’s member services telephone number.

What level of service will SJHIA provide?

SJHIA will file claims for the above referenced therapeutic components.  If medical records are requested by the insurance carrier to substantiate treatment and claims, SJHIA will furnish those as well as up to and including a Peer to Peer Appeal. If denied or if member appeal is needed to adjudicate claims, client may request SJHIA via an additional contract and fee to perform the member appeal.

Additionally, all claims are submitted to reimburse the plan subscriber.  Unfortunately, at times, the insurance carrier will mistakenly reimburse The Dorm. These reimbursements will be stopped and a request to reissue to plan subscriber will be made.

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: