Mental health inpatient authorizations

Coverage varies depending on plan.

Applies to:

Group HMO, EPO, POS and PPO plans

Individual MyPriority® HMO, POS and PPO plans

Medicare Advantage plans

Definition

When a member is admitted to a mental health facility as an inpatient for behavioral health treatment. 

Mental health inpatient policies

Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria. We also require ongoing clinical reviews to determine if the member continues to meet medical necessity criteria for treatment. 

Medical Necessity - 91447  

Criteria required for initial and concurrent medical necessity reviews includes but not limited to:

  • Chronic medical conditions
  • Stressors/symptoms
  • Psychosocial information
  • Psychotropic medications
  • Pertinent treatment history
  • Risk factors
  • Discharge planning details
  • Current symptoms and level of functioning
  • Treatment Recommendations

Mental health inpatient authorizations

Authorization is required. In addition to the member meeting medical necessity criteria, the residential program must meet our Residential Facility criteria. We also require ongoing clinical reviews to determine if the member continues to meet medical necessity criteria for treatment.

In-network providers

In-network providers can request authorization for mental health and substance use disorder services, evaluations and discharges using GuidingCare Auth Portal. 

Request an authorization

Out of network providers

If you’re a provider located within the state of Michigan and would like to join our provider network, visit our credentialing application page.

Out of network providers request mental health and substance use disorder services using our authorization request forms.