Applies to:

All Priority Health Choice, Inc., members: Medicaid, Healthy Michigan Plan

Mild to moderate conditions

Priority Health provides outpatient behavioral health therapy services for Medicaid members with mild to moderate mental health needs. This includes members experiencing or demonstrating mild to moderate psychiatric symptoms or signs of sufficient intensity to cause subjective distress or mildly disordered behavior, with minor or temporary functional limitations or impairments (self-care/daily living skills, social/interpersonal relations, educational/vocational role performance, etc.) and minimal clinical (self/other harm risk) instability.

Severe conditions, substance use disorders, specialized behavioral health services

Medicaid members with severe mental illness (adults), severe emotional disturbance (children), substance use disorders or developmental disabilities, as defined in the Michigan Mental Health Code, should be directed to their local pre-paid inpatient health plan (PIHP) for evaluation and treatment. 

Providers are responsible for referring members to their PIHP if they require specialized behavioral health services. 

Members who are being served through the PIHP system of care are generally not eligible to receive mental health outpatient services through Priority Health.

Helpful tools

Download this chart to help you better understand who's responsible for authorizations and payments: 

Mental Health & Substance Use Disorder Authorization and Payment Responsibility Grid

Find the correct PIHP

Bill the PIHP in the member's county of residence. The list of all PIHPs and regions can be found here:

• Regional PIHP contact information
• 10 Region PIHP directors and affiliates list

Coding help

• Review MDHHS's Behavioral Health Code Chart and Provider Qualifications workbook to find the specific code set to be billed by the member's PIHP. 
• Access MDHHS's Code Set Question / Answer Document Technical Assistance document. 

Medicaid resource

Below is the link to the MDHHS Medicaid Provider Manual for more information. 

• Medicaid Provider Manual - Go to the "Behavioral Health and Intellectual & Developmental Disability Support and Services" section, then Section 1.6, Beneficiary Eligibility

PHI consent tool 

To reduce confusion about when an individuals' consent is necessary to share health information, the Michigan Department of Health and Human Services (MDHHS) has additional resources available, to help clinicians and providers navigate the laws surrounding protected health information (PHI). 

There are multiple state and federal laws that address what health information can be shared, when it can be shared and with whom. These resources are intended to increase the flow of patient information from clinician to clinician, particularly in the case of behavioral health information.

You can access these tools by visiting the MDHHS website. 

Medicaid eligibility questions

Questions about Medicaid/Healthy Michigan Plan members' service eligibility should be directed to our Behavioral Health department. You can reach us at 616.464.8500 during business hours to verify eligibility.

Medicaid authorization and payment questions

The Michigan Department of Community Health has created a chart listing authorization and payment responsibilities by type of service and place of service.