Coverage varies depending on plan.
Coverage varies depending on plan.
Group HMO, EPO, POS and PPO plans
Individual MyPriority® HMO, POS and PPO plans
Medicare Advantage plans
When a member is admitted to a mental health facility as an inpatient for behavioral health treatment.
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:
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 can request authorization for mental health and substance use disorder services, evaluations and discharges using GuidingCare Auth Portal.
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.