Addiction and Recovery Education and News

SJHIA and New York Center for Living: What to Expect

We recognize that the nuances of managed healthcare and the claims submission process can often be difficult to navigate and understand.  Below are Frequently Asked Questions (FAQ) regarding the process of working with your insurance company in order to minimize confusion and maximize reimbursement.

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. New York Center for Living provides the option of utilizing insurance services through SJHIA to help patients obtain reimbursement for treatment.  You may visit their website at www.sjhia.com.

New York Center for Living will provide all required information to SJHIA in order to utilize insurance benefits. In turn, SJHIA will verify and communicate to Patient such information as whether Patient 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?

We strongly encourage you to contact SJHIA prior to enrollment to discuss your specific insurance coverage. A consultation with SJHIA will provide answers to the many questions that arise regarding insurance benefits, along with advice on what approach will best serve the Patient.

To contact SJHIA, please email info@sjhealthinsuranceadvocates.com. Tell them that you are emailing about New York Center for Living.

What happens if services are approved?

SJHIA will contact the Patient’s insurance carrier within the first 24-48 hours of admission.  If services are approved, SJHIA will provide that information to the Patient and/or their Representative. SJHIA will also continue to work with New York Center for Living and the Patient’s insurance company to complete ongoing reviews (typically every 5 – 7 sessions). SJHIA will continue to complete the authorization process until: a) services are denied; or c) the Patient is discharged.

In addition to obtaining insurance authorization, SJHIA manages the claim submission for services rendered. Specifically, SJHIA will submit claims for authorized services, at the daily rate, to the Patient’s insurance carrier upon completion of treatment.  Please note that it may take a minimum of thirty to forty-five (30 – 45) days for the Patient’s insurance carrier to process the claim. 

What happens if services are denied?

If/when services are denied, SJHIA will complete a Provider appeal, which is called a “doc-to-doc” or “peer review.” This process entails SJHIA reviewing information about the Patient with the insurance carrier’s doctor to further advocate for authorization of services. At that time, treatment will either be approved and reviews will continue; or treatment will be denied, and no further reviews will take place. SJHIA will communicate with Patient and/or their Representative regarding any denial.

Will SJHIA continue to appeal for coverage and reimbursement?

SJHIA will not continue to appeal for services following a denial on a “doc-to-doc” review.  If you are interested in discussing your member appeal options, you can feel free to contact SJHIA for additional information or guidance.

When can I expect to receive payment for services?

New York Center for Living is an out-of-network provider, thus claims often take slightly longer to be processed. As mentioned above, claims can take approximately thirty to forty-five (30 – 45) days to process.

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 typical allowed amounts.  Please feel free to reach out to SJHIA to discuss your individual case.

In order to maximize the Patient’s insurance benefits, the decision to utilize SJHIA’s services must be made within the first 24-48 hours of admission due to the time sensitivity in dealing with insurance. 

Is there a fee for services?

Yes, SJHIA charges a 10% contingency fee based on total health insurance reimbursement for the aforementioned services.

If services are not authorized and I choose to appeal post discharge can SJHIA still assist?

Yes, SJHIA can assist. The appeals process takes approximately four to six months. The fee for an appeal is a $2,500 retainer plus a 25% contingency fee based on total health insurance reimbursement.