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

The term "medical necessity" is used to mean care that is determined to be effective, appropriate and necessary to treat a given patient's disorder. To determine medical necessity for mental health inpatient treatment, the Priority Health Behavioral Health department relies on InterQual® Behavioral Health criteria and Priority Health medical policies:

Mental health inpatient authorizations

Authorization is required. Members/participants/beneficiaries must meet InterQual® Behavioral Health medical necessity criteria for urgent/emergent admission to mental health facilities.

In-network providers

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

Request an authorization

Out of network providers

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

Information needed to authorize services

  • Stressors/symptoms
  • Psychosocial information
  • Pertinent treatment history
  • Risk factors
  • Recommendation

We also require ongoing clinical reviews to determine if the member continues to meet medical necessity criteria for treatment.