SJHIA and The Dorm

Out-of-Network Insurance Processing Review:

The Dorm has arranged for SJHIA to assist its clients (if desired) in recovering treatment expenses that may be paid by insurance. The Dorm does not participate in any medical or behavioral health networks. It is a private practice 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, begin to file claims on your behalf. 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 the plan subscriber and an explanation of benefits (EOB) that explains the methods, policy, and rates used to calculate a claim reimbursement.

Clients of The Dorm are asked to forward any insurance communication for services rendered by The Dorm to SJHIA.  This includes explaining 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, clients must 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 specializing in behavioral health insurance authorization and claims management. The Dorm has arranged for SJHIA to help clients obtain reimbursement for treatment if they 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 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 and whether such coverage includes out-of-network providers, plan deductibles, and out-of-pocket limits.

Will SJHIA answer my questions about insurance benefits and authorizations?

SJHIA will answer the many questions regarding insurance benefits and advise 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 referenced below.  If the insurance carrier requests medical records to substantiate treatment and claims, SJHIA will furnish those upon receipt of such requests from the plan subscriber.  If denied or a member appeal is needed to adjudicate claims, the client may request SJHIA via an additional contract and fee to perform the member appeal.

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 total 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 member services telephone number.

What level of service will SJHIA provide?

SJHIA will file claims for the therapeutic components referenced below.  If the insurance carrier requests medical records to substantiate treatment and claims, SJHIA will furnish those up to and including a peer-to-peer appeal. If denied or a member appeal is needed to adjudicate claims, the 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 not be deposited. The plan subscriber may coordinate reissue with the healthcare insurance company.

Any questions or concerns regarding the services provided by The Dorm along with the amount of such services should be directed to The Dorm.

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.

Please note that reimbursement from the insurance plan may be allocated to the client’s deductible and out-of-pocket maximum if not yet met when claims are filed.

Is there a fee for this service?

No. The Dorm contracts with SJHIA. There is no additional fee for this service.

Can I determine how much money I will receive back if the claims are approved?

SJHIA can guide your reimbursement based on your specific policy and the typically allowed amounts. Please see the following schedule of expected allowed amounts by service: